Engaging Trusted Messengers to Increase COVID-19 Pediatric Vaccine Uptake in Philadelphia: Lessons from the VaxUpPhillyFamilies program.

INTRODUCTION: Communities of color had higher rates of Coronavirus (COVID-19) infection and lower rates of COVID-19 vaccination during the pandemic. Parental concern about the safety and necessity of pediatric COVID-19 vaccines contribute to low childhood vaccination. Enlisting parents and caregivers as trusted messengers is an evidence-based approach to mitigate this challenge. VaxUpPhillyFamilies was formed to engage parents and caregivers as vaccine ambassadors to increase vaccination rates in children of color. This study aimed to understand the key benefits, challenges, and lessons learned from the VaxUpPhillyFamilies program. METHODS: Three online debriefing sessions with ambassadors were conducted between September 7 and October 24, 2022, to share best practices, address challenges, receive emerging vaccine information, and provide support. Thematic analysis was utilized to develop broad themes and subthemes. RESULTS: Four themes with corresponding subthemes were identified: 1) Motivations to Become an Ambassador: a) improving the health of the community and b) personal satisfaction; 2) Defining Success: a) community interactions and b) influencing opinions; 3) Best Approaches: a) being mentally prepared with facts, b) addressing community health needs beyond COVID-19, c) demonstrating empathy, d) "meeting them where they're at" by motivational interviewing, and e) building trust and connection; 4) Challenges: a) changes in vaccine guidelines, b) vaccine misinformation, c) varied perceptions of severity of COVID-19 illness and benefits of the vaccine, d) breakdown of communication from trusted sources, and e) structural barriers to engagement. CONCLUSION: Parents and caregivers were a resource for delivering evidence-based messaging about COVID-19 and other health challenges. To effectively equip parents and caregivers as public health ambassadors, it is critical to offer training in engagement strategies, to identify and combat misinformation, and to provide support in navigating challenges. VaxUpPhillyFamilies program is a model for future public health campaigns.

Public Librarian Perceptions of Assisting Immigrant Patrons: Results from a Multi-State Survey.

Public libraries in the United States (U.S.) are important sources of health information. Immigrants comprise a large portion of the U.S. population, and research suggests that public libraries help immigrants adjust to life in a new country. Public libraries help immigrants access information directly related to health and provide programs that have indirect impacts on health outcomes, including learning a new language and forging social ties. The purpose of this paper was to examine perspectives from librarians related to interactions with immigrant patrons and how their library supports them in this role. Public librarians (n = 205) from two selected U.S. states completed an online survey focusing on how comfortable they were in helping immigrants with inquiries related to health and the role of the public library in supporting librarians in this endeavor. Respondents generally reported high levels of comfort interacting with immigrants, although there was limited interaction on potentially sensitive topics (i.e., immigration, health). Library staff perceived that libraries overall were not effective in meeting the needs of immigrant populations and that librarians were infrequently offered professional training related to cultural competency and diversity. The findings echo previous studies that demonstrate the need for professional development to ensure that librarians are aware of library resources available to assist immigrant patrons. Findings from this study suggest opportunities for public health professionals and public librarians to collaborate to ensure the provision of reliable resources, health information, and referrals to community-based services.

Food Allergy Management for Adolescents Using Behavioral Incentives: A Randomized Trial.

OBJECTIVE: We sought to evaluate the use of behavioral economics approaches to promote the carrying of epinephrine auto-injectors (EAIs) among adolescents with food allergies. We hypothesized that adolescents who receive frequent text message nudges (Intervention 1) or frequent text message nudges plus modest financial incentives (Intervention 2) would be more likely to carry their epinephrine than members of the usual care control group. METHODS: We recruited 131 adolescents ages 15 to 19 with a food allergy and a current prescription for epinephrine to participate in a cohort multiple randomized controlled trial. Participants were randomly assigned to participate in Intervention 1, Intervention 2, or to receive usual care. The primary outcome was consistency of epinephrine-carrying, measured as the proportion of checkpoints at which a participant could successfully demonstrate they were carrying their EAI, with photo-documentation of the device. RESULTS: During Intervention 1, participants who received the intervention carried their EAI 28% of the time versus 38% for control group participants (P = .06). During Intervention 2, participations who received the intervention carried their EAI 45% of the time versus 23% for control group participants (P = .002). CONCLUSIONS: Text message nudges alone were unsuccessful at promoting EAI-carrying but text message nudges combined with modest financial incentives almost doubled EAI-carriage rates among those who received the intervention compared with the control group. However, even with the intervention, adolescents with food allergies carried their EAI <50% of the time. Alternative strategies for making EAIs accessible to adolescents at all times should be implemented.

Community-Based COVID-19 Vaccine Clinics in Medically Underserved Neighborhoods to Improve Access and Equity, Philadelphia, 2021-2022.

Vaccination remains key to reducing the risk of COVID-19-related severe illness and death. Because of historic medical exclusion and barriers to access, Black communities have had lower rates of COVID-19 vaccination than White communities. We describe the efforts of an academic medical institution to implement community-based COVID-19 vaccine clinics in medically underserved neighborhoods in Philadelphia, Pennsylvania. Over a 13-month period (April 2021-April 2022), the initiative delivered 9038 vaccine doses to community members, a majority of whom (57%) identified as Black. (Am J Public Health. 2022;112(12):1721-1725. https://doi.org/10.2105/AJPH.2022.307030).

Design, Implementation, and Outcomes of a Volunteer-Staffed Case Investigation and Contact Tracing Initiative at an Urban Academic Medical Center.

Importance: The COVID-19 pandemic has claimed nearly 6 million lives globally as of February 2022. While pandemic control efforts, including contact tracing, have traditionally been the purview of state and local health departments, the COVID-19 pandemic outpaced health department capacity, necessitating actions by private health systems to investigate and control outbreaks, mitigate transmission, and support patients and communities. Objective: To investigate the process of designing and implementing a volunteer-staffed contact tracing program at a large academic health system from April 2020 to May 2021, including program structure, lessons learned through implementation, results of case investigation and contact tracing efforts, and reflections on how constrained resources may be best allocated in the current pandemic or future public health emergencies. Design, Setting, and Participants: This case series study was conducted among patients at the University of Pennsylvania Health System and in partnership with the Philadelphia Department of Public Health. Patients who tested positive for COVID-19 were contacted to counsel them regarding safe isolation practices, identify and support quarantine of their close contacts, and provide resources, such as food and medicine, needed during isolation or quarantine. Results: Of 5470 individuals who tested positive for COVID-19 and received calls from a volunteer, 2982 individuals (54.5%; median [range] age, 42 [18-97] years; 1628 [59.4%] women among 2741 cases with sex data) were interviewed; among 2683 cases with race data, there were 110 Asian individuals (3.9%), 1476 Black individuals (52.7%), and 817 White individuals (29.2%), and among 2667 cases with ethnicity data, there were 366 Hispanic individuals (13.1%) and 2301 individuals who were not Hispanic (82.6%). Most individuals lived in a household with 2 to 5 people (2125 of 2904 individuals with household data [71.6%]). Of 3222 unique contacts, 1780 close contacts (55.2%; median [range] age, 40 [18-97] years; 866 [55.3%] women among 1565 contacts with sex data) were interviewed; among 1523 contacts with race data, there were 69 Asian individuals (4.2%), 705 Black individuals (43.2%), and 573 White individuals (35.1%), and among 1514 contacts with ethnicity data, there were 202 Hispanic individuals (12.8%) and 1312 individuals (83.4%) who were not Hispanic. Most contacts lived in a household with 2 to 5 people (1123 of 1418 individuals with household data [79.2%]). Of 3324 cases and contacts who completed a questionnaire on unmet social needs, 907 (27.3%) experienced material hardships that would make it difficult for them to isolate or quarantine safely. Such hardship was significantly less common among White compared with Black participants (odds ratio, 0.20; 95% CI, 0.16-0.25). Conclusions and Relevance: These findings demonstrate the feasibility and challenges of implementing a case investigation and contact tracing program at an academic health system. In addition to successfully engaging most assigned COVID-19 cases and close contacts, contact tracers shared health information and material resources to support isolation and quarantine, thus filling local public health system gaps and supporting local pandemic control.

Patient Perceptions About Opioid Risk Communications Within the Context of a Randomized Clinical Trial.

Importance: Opioid overdose rates continue to increase, and extant literature suggests that many individuals who use heroin were first introduced to opioids through a medical prescription. Objective: To explore patient experiences related to decisions regarding analgesia after an emergency department visit within the context of a randomized clinical trial aimed to test the efficacy of risk communication interventions on treatment preference, risk recall, and use of opioids. Design, Setting, and Participants: This qualitative study of 36 patients making decisions regarding analgesia included qualitative interviews with participants in 2 risk intervention groups. Interviews were audio recorded, transcribed, and edited to remove identifying information to protect the confidentiality of participants. Interviews were conducted from June 4, 2019, to August 6, 2019. We conducted thematic analysis from August to December 2019 using a mixed inductive and deductive approach. Participants received $20 in compensation. The study was conducted in 4 geographically diverse emergency departments in the United States. Participants were adults presenting to the emergency department with either musculoskeletal back or neck pain or kidney stone-related pain. Eligibility criteria included being aged 18 to 70 years, capable of providing informed consent, English speaking or having English comprehension, eligible for emergency department discharge within 24 hours of enrollment, and able to access email or a smartphone. Interventions: Participants enrolled from the main randomized clinical trial received 1 of 2 risk interventions: a probabilistic opioid risk tool or a narrative-enhanced probabilistic risk tool (ie, participants viewed eight 1- to 3-minute short videos of patients discussing their experiences with pain treatment and positive and negative experiences with opioid use). Main Outcomes and Measures: Factors reported by participants to have influenced their decision-making regarding acute pain and treatment. Results: Thirty-six participants were interviewed, 18 in the group who received the probabilistic risk tool alone and 18 in the group who received the additional narrative-enhanced probabilistic risk tool intervention. The median age was 38 years (range, 21-67 years), 22 individuals were female (61%), 14 were Black or African American (39%), and 14 were White (39%). Five themes emerged from the analysis in the following domains: the factors associated with the risk interventions; clinician paternalism; analgesia attributes and previous experiences; individual self-identity, attitudes, and values; and perceptions of clinician bias. Conclusions and Relevance: Most participants commented on the powerful lessons they learned from the risk interventions. More research is needed to understand how patients incorporate risk information into their decision-making process.

Substance Use and Overdose in Public Libraries: Results from a Five-State Survey in the US.

In the U.S., overdoses have become a health crisis in both public and private places. We describe the impact of the overdose crisis in public libraries across five U.S. states, and the front-line response of public library workers. We conducted a cross-sectional survey, inviting one worker to respond at each public library in five randomly selected states (CO, CT, FL, MI, and VA), querying participants regarding substance use and overdose in their communities and institutions, and their preparedness to respond. We describe substance use and overdose patterns, as well as correlates of naloxone uptake, in public libraries. Participating library staff (N = 356) reported witnessing alcohol use (45%) and injection drug use (14%) in their libraries in the previous month. Across states surveyed, 12% of respondents reported at least one on-site overdose in the prior year, ranging from a low of 10% in MI to a high of 17% in FL. There was wide variation across states in naloxone uptake at libraries, ranging from 0% of represented libraries in FL to 33% in CO. Prior on-site overdose was associated with higher odds of naloxone uptake by the library (OR 2.5, 95% CI 1.1-5.7). Although 24% of respondents had attended a training regarding substance use in the prior year, over 90% of respondents wanted to receive additional training on the topic. Public health professionals should partner with public libraries to expand and strengthen substance use outreach and overdose prevention efforts.

Evaluation of a Contact Tracing Training Program and Field Experience.

Introduction: The study objective was to evaluate a contact tracing training program and the role of contact tracing on volunteers' professional development. Methods: A COVID-19 contact tracing program was conducted at an urban academic medical center, in collaboration with the local health department, between March 2020 and May 2021. Contact tracers, most of whom were health professions students, completed pretraining and post-training surveys to assess knowledge and self-efficacy to conduct contact tracing, plus an 18-month follow-up survey regarding career impacts. Results: We observed statistically significant post-training increases in knowledge and self-efficacy to conduct contact tracing. Contact tracers described benefiting from training regarding cultural humility, empathy, and trauma-informed interviewing. They also expressed a deeper understanding of COVID-19 inequities and their structural causes and reported that the work was emotionally demanding. Conclusions: Key to pandemic preparedness is having a trained and supported workforce. This study showed how contact tracing training and field experience strengthened students' education in the health professions by sharpening interpersonal skills and structural competency and by generating insights regarding current gaps in both public health infrastructure and support for vulnerable populations.

How do public libraries respond to patron queries about opioid use disorder? A secret shopper study.

Background: Improving linkage to opioid use disorder (OUD) treatment and services is a public health priority. Public libraries, a community resource for health information, may be well positioned to support and guide people who use drugs, as well as their families and friends. In this study, we sought to evaluate the availability and types of resources offered to patrons inquiring about OUD information, OUD treatment, and naloxone access. Methods: We conducted an audit (secret shopper) study from April 2019 to June 2019 in which an auditor anonymously called Pennsylvania public libraries. We used a purposive sampling strategy to select libraries located in geographically diverse regions across the urban-rural continuum. We categorized responses and verified via phone or website whether referrals to treatment centers and other organizations provided OUD treatment or services. Results: We obtained responses from 100 public libraries located across 48 of the 67 counties in Pennsylvania. Among the libraries that responded, 57 provided health information resources (e.g., books, websites) and 82 provided "next step" referrals to an organization that could provide further assistance. Among the libraries that provided referrals, 39 were to treatment centers, of which 33 were specifically to treatment centers that offer medications for OUD. Of the responding libraries, 28 communicated information about naloxone access. Conclusion: Public libraries can and do connect patrons to OUD treatment and support services; however, there is wide interlibrary variation in the resources presented, demonstrating opportunities for improvement in how libraries engage and refer patrons with substance use needs.

Public libraries as partners in confronting the overdose crisis: A qualitative analysis.

BACKGROUND: The overdose crisis is affecting public libraries. In a 2017 survey of public librarians, half reported providing patrons support regarding substance use and mental health in the previous month, and 12% reported on-site drug overdose at their library in the previous year. Given the magnitude of the overdose crisis and the fact that public libraries host 1.4 billion visits annually, our aim was to understand how libraries currently assist with substance use and overdose and how they can further address these issues. Methods: We conducted semi-structured interviews with 44 public library staff from across the U.S. attending a national meeting in March 2018. Interviews addressed attitudes and experiences regarding drug use, overdose, and overdose response in libraries. We analyzed interviews using thematic content analysis guided by the Consolidated Framework for Implementation Research. Results: Participants were from 26 states. Among libraries in this sample, 14% had experienced an on-site drug overdose and 7% stocked naloxone at the time of study. Nearly all participants reported substance use as a prominent concern among patrons and their families, as well as in the library itself. Many participants were willing to provide support to patrons and even administer naloxone, but they often lacked preparation, resources, or institutional support. Participants also expressed interest in providing information or referrals to people who use drugs (PWUD), but such efforts were often stymied by inadequate community resources. Finally, participants expressed interest in strengthening partnerships between public libraries and health and social service organizations. Conclusions and Relevance: Public library staff routinely engage PWUD, and based on prior studies, nearly 2,000 of U.S. public libraries can expect an on-site overdose in the next year. Findings from our work highlight the need for further study about how public libraries can act as part of comprehensive, community-based strategies to address the opioid epidemic.

Overdose Awareness and Reversal Trainings at Philadelphia Public Libraries.

PURPOSE: To evaluate an overdose response training program in public libraries. DESIGN: Mixed methods evaluation including pre- and post-intervention questionnaires and debriefing interviews. SETTING: Ten Philadelphia public libraries. SAMPLE: Overdose response training participants (library staff and community members). INTERVENTION: Public, hour-long overdose response trainings run by the Philadelphia Department of Public Health, the Free Library of Philadelphia, and the University of Pennsylvania between March and December 2018. MEASURES: Questionnaires assessed motivation for attending trainings, overdose response readiness, and intention to acquire and carry naloxone. Debriefing interviews elicited training feedback. ANALYSIS: We assessed changes in overdose response readiness and intention to carry naloxone and performed thematic analysis on interview data. RESULTS: At 29 trainings, 254 people attended, of whom 203 (80%) completed questionnaires and 23 were interviewed. 30% of participants had witnessed an overdose, but only 3% carried naloxone at baseline. Following training, overdose response readiness and intention to acquire/carry naloxone improved significantly (P < .01). Interviewees nonetheless noted that they experienced barriers to naloxone acquisition, including cost, stigma, and concern regarding future insurability. Trainings subsequently included naloxone distribution. Interviewees reported that public libraries were welcoming, nonstigmatizing venues. CONCLUSION: In Philadelphia, library-based overdose response trainings were well-attended and reached a population with prior overdose encounters. Similar trainings could be deployed as a scalable overdose prevention strategy in the nation's 16 568 public libraries.

Health Policy and Privacy Challenges Associated With Digital Technology.

Importance: Digital technology is part of everyday life. Digital interactions generate large amounts of data that can reveal information about the health of individual consumers (the digital health footprint). Objective: Τo describe health privacy challenges associated with digital technology. Design, Setting, and Participants: For this qualitative study, In-depth, semistructured, qualitative interviews were conducted with 26 key experts from diverse fields in the US between January 1 and July 31, 2018. Open-ended questions and hypothetical scenarios were used to identify sources of digital information that contribute to consumers' health-relevant digital footprints and challenges for health privacy. Participants also completed a survey instrument on which they rated the health relatedness of digital data sources. Main Outcomes and Measures: Health policy challenges associated with digital technology based on qualitative responses to expert interviews. Results: Although experts' ratings of digital data sources suggested a possible distinction between health and nonhealth data, qualitative interviews uniformly indicated that all data can be health data, particularly when aggregated across sources and time. Five key characteristics of the digital health footprint were associated with health privacy policy challenges: invisibility (people are unaware of how their data are tracked), inaccuracy (data in the digital health footprint can be inaccurate), immortality (data have no expiration date and are aggregated over time), marketability (data have immense commercial value and are frequently bought and sold), and identifiability (individuals can be readily reidentified and anonymity is nearly impossible to achieve). There are virtually no regulatory structures in the US to protect health privacy in the context of the digital health footprint. Conclusions and Relevance: The findings suggest that a sector-specific approach to digital technology privacy in the US may be associated with inadequate health privacy protections.

Local health departments and the implementation of evidence-based policies to address opioid overdose mortality.

BACKGROUND: In the context of the opioid overdose crisis, local health departments are on the front lines, coordinating programs and services and translating state and federal policies into community action. While media reports describe growth of Overdose Education and Naloxone Distribution (OEND) programs among local health departments, little is known about program features, scope, and target populations. Methods: We surveyed health departments in 180 United States counties with high overdose mortality rates. Results: Among health officials from 54 counties (30% response), many counties reported implementation of evidence-based practices, with a high degree of programmatic variation. The majority of responding health departments (94%) conducted overdose education and naloxone distribution (OEND) programs. Programs were heterogeneous in scale, with a reported median of 250 naloxone kits (range 1-25,000 kits) acquired for community distribution. In addition, four in five respondents were aware of their state's standing order policy for increasing naloxone access. While the majority of respondents reported county-level availability of at least one form of evidence-based medications to treat opioid use disorder (MOUD), many reported no availability of buprenorphine (33%) or methadone (43%). Conclusions: Local health departments are vital to reducing opioid overdose mortality, and many are implementing relevant evidence-based practices. To support further adoption of potentially life-saving strategies, health departments need adequate funding and staffing as well as policies and guidelines to support implementation.

A Randomized Trial to Encourage Healthy Eating Through Workplace Delivery of Fresh Food.

PURPOSE: This study aimed to increase the consumption of home-cooked meals among employees at a large urban worksite through a fully subsidized Community Supported Agriculture (CSA) program. DESIGN: Randomized trial. SETTING: Worksite in a large northeast city. PARTICIPANTS: Employees were recruited through flyers, e-mail listservs, and outreach from departmental administrators (n = 60). INTERVENTION: Intervention participants received 8 biweekly fresh food deliveries through a CSA program. They also received cooking education and support. Control participants received usual employee benefits. MEASURES: Consumption of meals prepared at home was the primary end point. Increased consumption of fresh fruits and vegetables was the secondary end point, and food insecurity was an exploratory end point. ANALYSIS: Poisson regression was used to assess mean differences in weekly consumption of home-cooked meals. To assess differences in fruit and vegetable consumption and food insecurity, binary logistic regression was used to estimate odds ratios. RESULTS: Compared to the control group, intervention participants consumed 29% more home-cooked meals per week (P < .01). Fruit and vegetable consumption also increased among intervention participants. The odds of at least twice-daily fruit consumption were 3.8 times higher among intervention participants than among controls, and the odds of at least twice-daily vegetable consumption were 6.2 times higher among intervention participants than among controls. Compared to control participants, intervention participants experienced a statistically significant 89% reduction in the odds of reporting food insecurity at follow-up, when controlling for baseline food insecurity. Participants reported perceived intervention benefits, including the opportunity to experiment with new, healthful foods without financial risk, as well as the social value of sharing recipes, food, and related conversation with colleagues. CONCLUSION: The study demonstrated the feasibility and potential positive effects of a subsidized workplace CSA program, augmented with cooking education and support.

Planning for Food Access During Emergencies: Missed Meals in Philadelphia.

OBJECTIVES: To illustrate the effects that minor social or environmental disruptions could have on the food access of low-income households in Philadelphia, Pennsylvania, and provide suggestions for how cities can better incorporate food into emergency planning. METHODS: Using publicly available data and stakeholder interviews (n = 8) in 2017, we projected the number of meals that would be missed during environmental and social disruptions in Philadelphia, a major US city with a high poverty rate. RESULTS: As our projections in Philadelphia indicate, even just 3 days of school closures could result in as many as 405 600 missed meals for school-aged children. CONCLUSIONS: These scenarios provide valuable lessons for other cities to proactively plan for food access continuity in times of uncertainty. Public Health Implications. City planners and other city agencies need to include food as a routine part of emergency planning and redefine the threshold at which emergency response protocols are triggered to better ensure protection of low-income and underserved populations.