Catalyzing Technology-Based Innovation in Teen Pregnancy Prevention: an Implementation Model and Findings from a Human-Centered Design Initiative.

From 2015 to 2021, the US Department of Health and Human Services' Teen Pregnancy Prevention (TPP) program funded Power to Decide, a national reproductive health nonprofit organization, to catalyze innovation in adolescent sexual and reproductive health through the development of technology-based interventions. Power to Decide's initiative, Innovation Next, supported twenty innovation teams in using human-centered design (HCD) to develop new products, services, and programs. We describe the Innovation Next implementation model, which can inform future efforts to develop innovative, technology-based TPP programs using HCD. To that end, we draw on quantitative and qualitative data collected for program improvement to summarize key implementation findings.

Public Health Learning Agenda for Systems Change Toolkit: National Pilot Evaluation Results.

CONTEXT: There have been multiple calls in the United States for public health workforce development approaches that expand practitioner skill sets to respond to profound inequities and improve population health more effectively. However, most workforce models address individual competencies that instead focus on collective approaches to systems change. PROGRAM: In response to this opportunity, the HRSA-funded Regional Public Health Training Centers (PHTCs) and the University of Illinois Chicago Policy, Practice, and Prevention Research Center (P3RC) released Creating a Learning Agenda for Systems Change: A Toolkit for Building an Adaptive Public Health Workforce (the Toolkit) in December 2020. We later supplemented the Toolkit with additional learning activities to launch the Learning Agenda Toolkit Pilot Test (Toolkit Pilot). IMPLEMENTATION: From June to August 2021, 24 diverse teams piloted the Toolkit. Teams completed a multistep process simulating the development of a learning agenda aimed at addressing community health issues and impacting systems change. EVALUATION: We conducted an evaluation process to assess the usability and impact of the Toolkit Pilot to inform its improvement and future implementation. An evaluation subcommittee analyzed worksheets completed by the Pilot Teams that are aligned to the Learning Agenda steps and conducted and analyzed 12 key informant interviews using concepts from the Toolkit Pilot Logic Model. FINDINGS AND DISCUSSION: Evaluation results suggest that most Pilot Teams found that the Toolkit Pilot offered a step-by-step process toward a clear vision that produced a concrete product on how to address community challenges through learning and systems change. Pilot Teams noted that the Toolkit Pilot provided exposure to and a unique focus on systems thinking; however, prior knowledge of systems thinking and systems change was important. Building readiness for systems change and having more time, resources, and technical assistance would be needed for future versions of the Learning Agenda Toolkit.

Learning to Lead: 3 Models to Support Public Health Leadership Development.

CONTEXT: The current public health system is underresourced and understaffed, which has been exacerbated by the coronavirus pandemic. In addition, there has been a decline in the public health workforce at both state and local levels during the last decade. While workforce numbers dwindle, public health systems have to address increasingly complex challenges-such as climate change, chronic diseases, and health equity-challenges that require skilled, adaptive leaders. This article describes the importance of leadership development and how 3 public health training centers (PHTCs) are building leadership skills in the public health workforce. PROGRAM: To address the need for public health leadership training, the PHTCs in the Health & Human Services (HHS) Regions 4, 7, and 10 all offer public health leadership institutes (PHLIs). IMPLEMENTATION: The 3 PHLIs discussed in this article vary in longevity (3-18 years), cohort length (8-12 months), and format (virtual, in-person, and hybrid); yet, all 3 emphasize adaptive leadership through a health equity lens and intentional opportunities to apply skills in practice. EVALUATION: Each PHLI conducts extensive evaluation based on Kirkpatrick's levels of evaluation and collects common metrics collected by all PHTCs. Data from the PHLIs illustrate high levels of satisfaction with learning, presentation of data, identification of workplace actions, and improvement of subject matter understanding. Each PHLI also has numerous stories of impact. DISCUSSION: With public health leaders leaving the workforce and the complexities of practice increasing, leadership training is critical to the current workforce and succession planning. These PHTCs provide a significant, enduring resource toward the development of our nation's public health leaders, as well as meeting the unique needs of their regions' workforces.

Reconsidering the "Place" in Field Placement.

Site-based, in-person field placement experiences prepare students for real-world community practice through reflection; direct, hands-on experience; and the completion of a project or set of deliverables that add value to the organization. These practice experiences encourage students to integrate classroom learning with the knowledge and skills of a workplace environment. In the Southeast United States, the Region IV Public Health Training Center (R-IV PHTC) provides students with practice experiences through the Pathways to Practice Scholars Field Placement Program. Before COVID-19, these field placement experiences were limited to in-person assignments in which students worked and lived in the communities they served. However, student and mentor experiences during the COVID-19 pandemic demonstrated that remote work arrangements offer a viable alternative to the onsite-only field placement experience. In this article, we describe student experiences with remote and hybrid work arrangements, highlight issues regarding equity and inclusion, and discuss implications for future public health practice.

Calmodulin binding to the dehydrogenase domain of NADPH oxidase 5 alters its oligomeric state.

Superoxide generated by NADPH Oxidase 5 (Nox5) is regulated by Ca2+ through the interaction of its self-contained Ca2+ binding domain and dehydrogenase domain (DH). Recently, calmodulin (CaM) has been reported to enhance the Ca2+ sensitivity of Nox5 by binding to the CaM-binding domain sequence (CMBD), in which the interaction between CaM and Nox5 is largely unclear. Here, we used the CMBD peptide and truncated DH constructs, and separately studied their interaction with CaM by fluorescence, calorimetry, and dynamic light scattering. Our results revealed that each half-domain of CaM binds one CMBD peptide with a binding constant near 106 M-1 and a binding enthalpy change of -3.81 kcal/mol, consistent with an extended 1:2 CaM:CMBD structure. However, the recombinant truncated DH proteins exist as oligomers, possibly trimer and tetramer. The oligomeric states are concentration and salt dependent. CaM binding appears to stabilize the DH dimer complexed with CaM. The thermodynamics of CaM binding to the DH is comparable to the peptide-based study except that the near unity binding stoichiometry and a large conformational change were observed. Our result suggests that the oligomeric states of Nox5, mediated by its DH domain and CaM, may be important for its superoxide-generating activity.

Binding of Nox5's EF-Hand domain to the peptides corresponding to the phosphorylatable region and regulatory inhibitory loop in its dehydrogenase domain.

Reactive oxygen species (ROS) produced by NADPH oxidase 5 (Nox5) are regulated by Ca2+ flux through the interactions of its self-contained EF-hand domain (EFD), dehydrogenase domain (DH), and transmembrane domain. Studies suggest that the regulatory EF-hand binding domain (REFBD) and phosphorylatable (PhosR) sequences within DH play an important role in Nox5's superoxide-generating activity. However, the interplay of the EFD-DH interaction is largely unclear. Here, we used two synthetic peptides corresponding to the putative REFBD and PhosR sequences, as well as DH construct proteins, and separately studied their binding to EFD by fluorescence spectroscopy and calorimetry. With mutagenesis, we revealed that the C-terminal half domain of EFD binds specifically to REFBD in a Ca2+-dependent manner, which is driven primarily by hydrophobic interactions to form a more compact structure. On the other hand, the interaction between EFD and PhosR is not Ca2+-dependent and is primarily dominated by electrostatic interactions. The binding constants (Ka) for both peptides to EFD were calculated to be in the range of 105 M-1. The formation of the binary complex EFD/REFBD and ternary complex EFD/REFBD/PhosR was demonstrated by fluorescence resonance energy transfer (FRET). However, EFD binding to PhosR appears to be not biologically important while the conformational change on its C-terminal half domain resembles a major factor in EFD-DH domain-domain interactions.

Metal binding and conformational studies of the calcium binding domain of NADPH oxidase 5 reveal its similarity and difference to calmodulin.

The superoxide-generating activity of Nox5 is regulated by Ca2+ flux, primarily through its self-contained calcium binding domain (EFD). Upon Ca2+ binding, Nox5's EFD undergoes a conformational change that exposes its buried hydrophobic residues. Previously, we determined the Ca2+ binding constants of the N-terminal half domain (N-EFD). Here we performed a similar characterization with its C-terminal lobe (C-EFD). Our studies revealed that the binding affinities (Ka's) of the EFD are in the range of 108-105 M-1 with a strong Ca2+ binding that occurs in the C-EFD. The 3rd Ca2+ binding site also binds Mg2+ (Ka = 4.53 × 103 M-1), where its high Ca2+ binding affinity becomes moderate in cellular conditions. The essential hydrophobic exposure upon metal binding was assessed with the analysis of the 1-anilino-8-naphthalene sulfonate (ANS) interaction via fluorescence and calorimetry. While the ANS fluorescence and binding studies agree with each other in general, the results do not correlate to the actual hydrophobic exposure content. The heat capacity change (ΔCp) of Ca2+ binding for EFD is -24.1 cal/mol.K, while those of N-EFD and C-EFD are -56.3 and -41.6 cal/mol·K, respectively, indicating a significant hydrophobic exposure and polar burial. The latter was confirmed by limited trypsin digestion. The comparison of Nox5's EFD to calmodulin, including homology modeling, was discussed in the report.Communicated by Ramaswamy H. Sarma.

Connecting Public Health Students to Rural and Underserved Areas: Promoting Health Equity Through Field Placement Experiences.

There is an increasing demand for public health workers due to the unmet needs of the poor and underserved populations. However, through field placement experiences, students can actively engage in their own learning while also addressing critical needs of rural and medically underserved populations. In this mixed-methods evaluation, we explored experiences of emerging public health practitioners who participated in the Region IV Public Health Training Center's Pathways to Practice Scholars program between 2014 and 2018. Based on student confidence level ratings and descriptions of field placement experiences, scholars participated in meaningful and enriching field placement experiences in rural areas or on behalf of medically underserved populations. Across all eight Council on Linkages Core Competency Domains, students recorded increased pre- to post-confidence scores, and for many, the field placement experience appeared to affirm their interest in addressing the needs of these communities in the future.

Simulation modeling analysis of sequential relations among therapeutic alliance, symptoms, and adherence to child-centered play therapy between a child with autism spectrum disorder and two therapists.

This study examined the sequential relations among three pertinent variables in child psychotherapy: therapeutic alliance (TA) (including ruptures and repairs), autism symptoms, and adherence to child-centered play therapy (CCPT) process. A 2-year CCPT of a 6-year-old Caucasian boy diagnosed with autism spectrum disorder was conducted weekly with two doctoral-student therapists, working consecutively for 1 year each, in a university-based community mental-health clinic. Sessions were video-recorded and coded using the Child Psychotherapy Process Q-Set (CPQ), a measure of the TA, and an autism symptom measure. Sequential relations among these variables were examined using simulation modeling analysis (SMA). In Therapist 1's treatment, unexpectedly, autism symptoms decreased three sessions after a rupture occurred in the therapeutic dyad. In Therapist 2's treatment, adherence to CCPT process increased 2 weeks after a repair occurred in the therapeutic dyad. The TA decreased 1 week after autism symptoms increased. Finally, adherence to CCPT process decreased 1 week after autism symptoms increased. The authors concluded that (1) sequential relations differ by therapist even though the child remains constant, (2) therapeutic ruptures can have an unexpected effect on autism symptoms, and (3) changes in autism symptoms can precede as well as follow changes in process variables.

Public health training center evaluation: a framework for using logic models to improve practice and educate the public health workforce.

The nation's 37 public health training centers (PHTCs) provide competency-based trainings and practice-based opportunities to advance the current and future public health workforces. The Emory PHTC, based in Atlanta, Georgia, has developed a comprehensive evaluation plan to address the many evaluation-related questions that must be answered to inform decisions that improve practice. This plan, based on the center's logic model, includes formative assessment, outcome evaluation, process evaluation, and programmatic evaluation. Rigorous evaluation has been used to (a) assess what is working, what is not working, and why; (b) guide decision making about program improvement; and (c) ensure efficient use of resources, such as time and money. This article describes how the Emory PHTC uses its logic model to guide development of a comprehensive evaluation plan and to create specific data collection tools. It also explains the process used to analyze data and make decisions to maximize effectiveness and ensure the best use of resources. Simply conducting trainings and providing opportunities for real-world application are not enough; it is critical to assess whether or not these educational opportunities are, in fact, educating.

The evidence base for effectiveness of preparedness training: a retrospective analysis.

OBJECTIVES: In 2007, the Centers for Disease Control and Prevention (CDC) commissioned an Evidence-Based Gaps Collaboration Group to consider whether past experience could help guide future efforts to educate and train public health workers in responding to emergencies and disasters. METHODS: The Group searched the peer-reviewed literature for preparedness training articles meeting three criteria: publication during the period when CDC's Centers for Public Health Preparedness were fully operational, content relevant to emergency response operations, and content particular to the emergency response roles of public health professionals. Articles underwent both quantitative and qualitative analyses. RESULTS: The search identified 163 articles covering the topics of leadership and command structure (18.4%), information and communications (14.1%), organizational systems (78.5%), and others (23.9%). The number of reports was substantial, but their usefulness for trainers and educators was rated only "fair" to "good." Thematic analysis of 137 articles found that organizational topics far outnumbered leadership, command structure, and communications topics. Disconnects among critical participants--including trainers, policy makers, and public health agencies--were noted. Generalizable evaluations were rare. CONCLUSIONS: Reviews of progress in preparedness training for the public health workforce should be repeated in the future. Governmental investment in training for preparedness should continue. Future training programs should be grounded in policy and practice needs, and evaluations should be based on performance improvement.

Screening asymptomatic adolescent men for Chlamydia trachomatis in school-based health centers using urine-based nucleic acid amplification tests.

BACKGROUND: Urine-based screening for Chlamydia trachomatis using highly sensitive and specific nucleic acid amplification tests offers a unique opportunity to screen men attending school-based health centers. METHODS: As part of a large multicenter chlamydia screening project in men, 1434 students were enrolled; 1090 in high schools in Baltimore and 344 middle and high-school students in Denver. Students were screened for chlamydia using urine-based nucleic acid amplification tests at well adolescent visits, acute care visits, or visits for other reasons, such as sports physicals. A self-administered survey to ascertain sexual risk behaviors was used. Data were analyzed separately for Baltimore and Denver, with univariate and multivariate logistic regression analysis. RESULTS: The overall prevalence in asymptomatic adolescent men was 6.8% (7.5% in Baltimore and 4.7% in Denver, P = n.s.). Students in Denver were older, more racially diverse, and more likely to have had intercourse in the previous 2 months than students in Baltimore. Students in Baltimore were more likely than those in Denver to have used a condom at last intercourse with casual and main partners. Among men in Denver but not Baltimore, condom use at last intercourse with both casual (OR 0.15, 95% CI, 0.03, 0.78) and main partners (OR 0.30, 95% CI, 0.10, 0.91) was protective against infection. The only risk factor for CT infection in Baltimore students was age (OR 1.47, 95% CI, 1.23, 1.75). In multivariate analysis that included age (as a continuous variable), race, history of an STI, any sex partner in the last 2 months, >1 sex partner in the past 12 months, a new partner in the last 2 months, and condom use with last main and last casual partner, age (adjusted odds ratio 1.34, 95% CI, 1.11, 1.62) and black race (adjusted odds ratio 2.37, 95% CI, 1.21, 4.63) were the only variables associated with testing chlamydia positive. CONCLUSIONS: School-based health centers are important venues in which to perform urine-based screening for chlamydia in sexually active, asymptomatic males, especially in high prevalence communities, and such screening provides the opportunity to identify and treat substantial numbers of chlamydia infections.

Rate and predictors of repeat Chlamydia trachomatis infection among men.

BACKGROUND: Chlamydia trachomatis (Ct) infection, especially repeat infection, is associated with serious sequelae among women, including pelvic inflammatory disease, ectopic pregnancy, and infertility. There are few reports evaluating repeat infection and predictors among men treated for Ct infection. OBJECTIVE: To measure the predictors and incidence of repeat Ct infection among men. METHODS: Men 15 to 35 years of age were screened for Ct infection in different venues in Baltimore, Denver, and San Francisco using urine-based nucleic acid amplification tests. Men with Ct infection were evaluated for repeat Ct infection from February 2001 until September 2003. Enrolled men had a baseline, 1-month, and 4-month follow-up visit and were tested for Ct infection at each visit. Project staff sought to locate and notify all female sex partners of infected men during the study to provide testing and treatment. We evaluated predictors of repeat Ct infection, time to infection, and incidence of infection. RESULTS: Three hundred fifty-nine men were recruited into the study and 272 (76%) had at least 1 follow-up visit with Ct results. Repeat infection occurred in 13% of men with Ct infection; there was no significant difference in repeat infection by site (Denver 13%, Baltimore 13%, San Francisco 12%). Independent predictors of repeat infection were history of an STD and venue. Incidence of repeat infection was 45.4 infections per 100 person years. CONCLUSION: Repeat Ct infection is common among men and similar in geographically distinct cities. Incidence of repeat Ct infection support routine rescreening of men within the first 3 months after Ct infection.

Age-bridging among young, urban, heterosexual males with asymptomatic Chlamydia trachomatis.

OBJECTIVES: To determine the prevalence of age-bridgers among urban males aged 14-24 years, asymptomatically infected with chlamydia and to determine factors that distinguish age-bridgers from non age-bridgers. An index was defined as an age-bridger if within 2 months, he had had at least two sexual partners who differed from him in age by > or =2 years. METHODS: Infected males provided data about themselves and up to four sexual partners in the past 2 months. Bivariate and multivariable logistic regression was used in the analysis. RESULTS: The prevalence of age bridging was 21% in Baltimore and 26% in Denver. In both cities, in bivariate analysis, age-bridgers and their partners engaged in significantly more risky sexual behaviours. In adjusted multivariable analysis after controlling for number of sexual partners, age bridging was associated with having a sexual partner in the past 2 months, who, at time of last sexual intercourse, was drinking. CONCLUSION: Age-bridgers represented major proportions of the study populations and, along with their sexual partners, were more likely to engage in risky sexual behaviours. Male age-bridgers may be key players in the transmission of sexually transmitted infections among youth linking age-disparate sexual networks.

Discussing HIV serostatus with prospective sex partners: a potential HIV prevention strategy among high-risk men who have sex with men.

OBJECTIVE: To study factors associated with HIV serostatus discussions among men who have sex with men (MSM). DESIGN: The authors conducted a cross-sectional survey among MSM visiting an urban sexually transmitted infection (STI) clinic. METHODS: MSM were asked about sex partner recruitment, serostatus of partners, condom use, drugs use, and HIV serostatus discussions with sex partners. RESULTS: Among 1,400 MSM reporting occasional sex partners, serostatus discussion with 100% of partners was reported by 509 (36.3%), with 50% to 99% of partners by 263 (18.8%), and with <50% of partners by 628 (44.9%). Factors associated with serostatus discussion included lower number of sex partners, anal sex with an occasional partner, and sex partner recruitment through the Internet. Partner recruitment in bathhouses and having sex with both men and women were negatively associated. CONCLUSIONS: Discussion of HIV serostatus was common among MSM studied. Although this strategy has limitations, interventions should address HIV status discussions. Because the Internet may facilitate these discussions, web-based interventions should be evaluated.

Sex partner selection, social networks, and repeat sexually transmitted infections in young men: a preliminary report.

GOAL: The goal of this study was to examine the risk for repeat sexually transmitted infections (STIs) associated with reducing the number of sex partners who come from within the social networks of males 13 to 25 years old in Baltimore, Maryland, and Denver, Colorado. STUDY: Asymptomatic males diagnosed with chlamydia and/or gonorrhea as part of an asymptomatic chlamydia and gonorrhea male screening project were recruited and interviewed about their sexual behaviors and their perceptions of social characteristics and sexual behaviors of their sex partners. We characterized the sex partners of each participant as belonging to or not belonging to his social network. We examined whether a decrease in percentage of sex partners who were in the participant's social network was associated with repeat infection. RESULTS: There were 47 participants in Baltimore and 92 in Denver. In both cities, there was a trend toward a finding that decreasing the percentage of sex partners belonging to a participant's social network was protective for repeat STI. CONCLUSION: These data suggest that interventions may need to be designed to reduce the prevalence of infection in the social networks of infected men.

Trends in clinic visits and diagnosed Chlamydia trachomatis and Neisseria gonorrhoeae infections after the introduction of a copayment in a sexually transmitted infection clinic.

BACKGROUND: To meet their sexually transmitted infection (STI) control mission, STI clinics most often offer services at no or minimal cost to clients. However, there is little knowledge about the effects of charging service fees on clinic attendance and STI identification. As a result of budget shortfalls, a clinic fee of 15 US dollars for Denver residents (up to 65 US dollars for nonresidents) was introduced in the Denver Metro Health (STI) Clinic (DMHC) in December 2002. We evaluated the effects of the fee on clinic utilization and diagnosed Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infections. METHODS: Using the DMHC computerized medical record system, we compared clinic visits and CT/GC diagnoses between the first 3 quarters of 2002 and 2003. We also compared CT/GC cases reported by DMHC with those reported by other Denver providers during 2002 and 2003. RESULTS: Compared with 2002, there were 3250 fewer visits (-28.5%) to DMHC in 2003 with no variance across quarters. CT diagnoses declined by 427 cases (-28.1%), disproportionately affecting women (-40%) and those under 20 (-42%). In addition, there were 332 fewer GC diagnoses (-38.1%) with no clear demographic preponderance. Although there were some decreases in non-DMHC CT/GC reports, the ratio of DMHC to non-DMHC reports declined from 0.42 to 0.33 (-21.4%) for CT and from 0.94 to 0.61 (-35.1%) for GC. CONCLUSIONS: Even a modest fee for service appears to have a major impact on the use of STI clinic services and may result in a significant effect on the ability to diagnose CT/GC infections, especially among those at highest risk.

Concurrent sexually transmitted infections (STIs) in sex partners of patients with selected STIs: implications for patient-delivered partner therapy.

BACKGROUND: Patient-delivered partner therapy (PDPT) is the practice of providing disease-specific antimicrobial agents to patients for delivery to their sex partners. Some partners who receive PDPT may forgo clinical evaluation, resulting in missed opportunities for the diagnosis and treatment of comorbid conditions. METHODS: We conducted a review of electronic charts for 8623 individuals attending 4 sexually transmitted disease clinics who were sex partners of patients with selected sexually transmitted infections (STIs). We evaluated the concordance between STIs diagnosed in partners and their reported exposures for which they might have received PDPT. RESULTS: Among 3503 female and 4647 heterosexual male partners, 19 (0.4%) of 4716 individuals tested were newly diagnosed with human immunodeficiency virus (HIV) infection, and 61 individuals (0.7%) had syphilis. Pelvic inflammatory disease was diagnosed in 133 women (3.8%). Seventy-two (3.2%) of 2226 female and heterosexual male partners reporting exposure to patients with chlamydial infection had gonorrhea diagnosed. Chlamydial infection or gonorrhea was diagnosed in 81 heterosexual male partners (10.3%) who reported contact with women with trichomoniasis. Among 473 men who have sex with men (MSM; including bisexual men), 13 (6.3%) of 207 tested were newly diagnosed with HIV infection, and 8 (1.7%) had syphilis. Six (6.1%) of 98 MSM reporting exposure to patients with chlamydial infection had gonorrhea diagnosed. CONCLUSIONS: Infrequent coinfections in female and heterosexual male partners exposed to patients with chlamydial infection or gonorrhea would not preclude use of PDPT. However, PDPT for male partners of women with trichomoniasis and for MSM requires further study.