Assessment of Patient Diversity and Equity of Care in a Tertiary Referral Interventional Pain Medicine Clinic.

OBJECTIVE: As an academic tertiary care interventional pain clinic, referrals are screened to ensure patients most likely to benefit from our services are accepted into the practice. The objective of this study is to assess for unconscious bias in the patient selection process. STUDY DESIGN: The demographic data of patients accepted into the practice was compared to patients not offered an appointment as a result of the screening process. SETTING: A university-based interventional pain center seeing patients referred from within the institution and broader community. METHODS: Three data management systems including an electronic health record, an appointment management system, and a financial records system, were queried to extract the patient characteristics and demographic data for all patients referred to the clinic between January 1, 2018, and December 31, 2019. Data were then analyzed for differences across these demographic characteristics to assess for unconscious bias. RESULTS: There were 3,465 patients meeting the criteria; 2975 were offered an appointment and 490 were not. The ages and genders were not clinically different between groups. There was a significant difference in the percentage of patients identifying as Hispanic being offered an appointment (1.82%) vs not being offered an appointment (3.88%) (P = 0.0016). There were no statistical differences in the race or preferred language of patients accepted for an appointment versus declined. CONCLUSIONS: While the screening process did not result in disparities across age, gender, race, or language preference, there was a statistical difference in patients identifying as Hispanic. As a result of this study, all patient identification has been removed from the review document to limit the likelihood of unconscious bias.

Assessing attitudes to ED-based HIV testing: Development of a short-structured survey instrument.

INTRODUCTION: Emergency Department (ED)-based HIV counseling and testing (HCT) has had a significant impact on improving rates of HIV diagnosis and linkage to care. Unfortunately, expansion of this strategy to low- and middle-income countries has been limited. Successful implementation of ED-based HCT is dependent on patient and provider acceptance of the intervention, and their attitudes and pre-existing biases towards the disease. This study sought to develop validated survey instruments to assess attitudes towards ED-based HCT. METHODS: This cross-sectional study surveyed patients and providers in three EDs in the Eastern Cape province, South Africa. A convenience sample of patients and providers in the ED were surveyed. Exploratory factor analysis was conducted using questions on attitudes to HIV testing to develop validated survey instruments. An ANOVA test assessed variance in attitudes towards HCT based on demographic variables collected. RESULTS: A total of 104 patient and 132 provider surveys were completed. Exploratory factor analysis resulted in a 17- and 7-question attitudes survey for patients and providers, respectively. Overall, 92.3% of patients and 70.7% of providers supported ED-based HCT, however, both groups displayed only mildly positive attitudes. Questions representing 'confidentiality' and 'stigma around HIV testing' had the least positive influence on patients' overall attitudes. Questions representing 'comfort with HIV testing' had the least positive influence on providers' overall attitudes. CONCLUSION: Our study demonstrated ED patients and providers are generally supportive of ED-based HCT. A validated survey instrument was able to provide a standardized approach to identify barriers to HCT implementation in an ED setting, across contexts. For successful implementation, behavioral interventions must focus on strengthening patient beliefs around confidentiality and the consent process, and providers' comfort levels with providing HIV testing services in the ED.

Illness representations of chronic obstructive pulmonary disease (COPD) to inform health education strategies and research design-learning from rural Uganda.

More than 90% of chronic obstructive pulmonary disease (COPD)-related deaths occur in low- and middle-income countries; however, few studies have examined the illness experiences of individuals living with and providing treatment for COPD in these settings. This study characterizes illness representations for COPD in Nakaseke, Uganda from the perspectives of health care providers, village health teams and community members (CMs) with COPD. We conducted 40 in-depth, semi-structured interviews (16 health care providers, 12 village health teams and 12 CMs, aged 25-80 years). Interviews were analyzed using inductive coding, and the Illness Representations Model guided our analysis. Stakeholder groups showed concordance in identifying causal mechanisms of COPD, but showed disagreement in reasons for care seeking behaviors and treatment preferences. CMs did not use a distinct label to differentiate COPD from other respiratory illnesses, and described both the physical and social consequences of COPD. Local representations can inform development of adapted educational and self-management tools for COPD.

Bending the Arc towards Equitable Partnerships in Global Health and Applied Training.

Background: Global health education has rapidly expanded in popularity, and many programs require applied practical experiences. Applied experiences are critical for global health training. Often a trainee from a high-income country travels to work with collaborators and partners in a low- or middle-income country. These experiences exist within partnerships between individuals and institutions that have varying objectives, including research, program implementation, or education. Attention is growing to ensure equity in these relationships in ways that are informed by the voices of collaborators and partners. Objectives: Understanding the experiences of LMIC collaborators in academic global health partnerships is essential. Our research aimed to capture views of our partners about factors impacting equitable global health partnerships. Methods: We conducted a small survey among global health collaborators and partners who host students on these experiences. Respondents were asked to rank enablers and barriers to equitable partnerships in priority order. Results were stratified by institutional affiliation and role. Results: Funding, time, engagement, and mutual opportunities for training are common enablers and barriers of global health partnerships. There were slight differences across different professional roles. Other reported factors that impact partnerships included language barriers, visa concerns, and identifying opportunities for collaboration. Conclusions: Our work highlights several barriers and enablers faced by partners that align with those reported across the global health education community. Equitable partnerships are possible and require substantial input at individual, interpersonal, and institutional levels. We reflect on two strategies to encourage partnership equity employed within our own work and discuss how these strategies can be applied more broadly.

Are you ready? A systematic review of pre-departure resources for global health electives.

BACKGROUND: There has been an exponential increase in the offering of short-term international field experiences in recent years in response to student demands for global health opportunities. Pre-departure preparation is an essential component to equip trainees with the adequate safety, wellness, and cultural competence needed to engage in a meaningful and mutually beneficial elective. This review seeks to quantify the plethora of pre-departure preparation training available to public health, clinical, and undergraduate trainees across the continuum of education for short-term experiences in low-and middle-income countries (LMICs). METHODS: We performed a systematic review of Pubmed, Embase, Web of Science, Scopus, and Ovid Global Health in February, 2018. A three-concept search was employed and included "global or international health"; "education or preparation of personnel/students"; and "field programs or travel." The study teamed used PRISMA reporting guidelines to conduct title and full-text reviews and conduct data extraction and analysis. RESULTS: The search returned 2506 unique articles. Of these, 55 met inclusion criteria and were included in the final review. Ninety one percent (91%) of articles focused on pre-departure trainings for medical students and residents. Nine thematic domains for short-term international field experiences emerged; culture, safety, and project-specific knowledge were the most frequently covered domains while mentorship, professionalism, and emotional wellness and culture shock were least common. Approximately half (53.3%) of studies specifically evaluated the pre-departure component of the international experience using a survey or evaluation form. Recommendations emerged from these evaluations including early engagement with international partners, inclusion of self-reflection exercises and site-specific content, and utilization of interactive approaches in learning. Some institutions face barriers to conducting pre-departure preparation such as lack of dedicated faculty, finances, and institutional support. CONCLUSIONS: Interest in pre-departure training for international experiences is growing but few programs conduct and publish evaluations of these trainings. Pre-departure trainings should be developed in partnership with receiving institutions and faculty and incorporate critical self- reflection throughout the experience. In addition to the experience itself, institutions need to evaluate these curricula to better understand how they influence trainees' capacity to effectively engage in LMIC settings.

Obese women's perceptions of weight gain during pregnancy: a theory-based analysis.

OBJECTIVE: Excess gestational weight gain (GWG) in obese women is linked to adverse maternal outcomes and is particularly pervasive among African Americans, who have the highest obesity rates in the USA. A better understanding of culturally relevant attitudes and perceptions of GWG is needed to develop targeted interventions to prevent excess GWG among this group. DESIGN: Using the constructs of Social Cognitive Theory, we explored attitudes and perceptions surrounding diet and exercise among low-income obese African-American pregnant women in Baltimore. We conducted twenty-one semi-structured in-depth interviews with pregnant adult women. SETTING: Participants were recruited from a referral clinic for obese pregnant women at a large urban hospital in Baltimore, MD, USA. PARTICIPANTS: Twenty-one low-income African-American adult females in the first two trimesters of pregnancy with BMI > 30·0 kg/m2. RESULTS: Lack of knowledge was not the main obstacle to healthy behaviours during pregnancy. Rather, food cravings and fatigue, an unhealthy physical food environment, limited self-efficacy for controlling excessive GWG, and a lack of adequate emotional and informational support impacted women's agency. While digital technology was discussed as a vehicle to promote maintenance of a healthy weight in pregnancy, further research is needed to test how it can be used to empower women to engage in healthy behaviours during pregnancy. CONCLUSION: Interventions to prevent excess GWG among African-American pregnant women should harness support from partners and family and must go beyond sharing of clinical knowledge to also include strategies that improve the food environment, diet quality and self-efficacy.

Urban-Rural Disparities in Chronic Obstructive Pulmonary Disease Management and Access in Uganda.

Introduction: Almost 90% of chronic obstructive pulmonary disease (COPD) deaths occur in low- and middle-income countries (LMICs), where there are large rural populations and access to health care for COPD is poor. The purpose of this study was to compare urban-rural provider experiences regarding systemic facilitators and barriers to COPD management and treatment access. Methods: We conducted a qualitative study using direct observations and in-depth semi-structured interviews with 16 and 10 health care providers in urban Kampala and rural Nakaseke, Uganda, respectively. We analyzed interviews by performing inductive coding using generated topical codes. Results: In both urban and rural districts, exposure to evidence-based practices for COPD diagnosis and treatment was limited. The biomedical definition of COPD is not well distinguished in rural communities and was commonly confused with asthma and other respiratory diseases. Urban and rural participants alike described low availability of medications, limited access to diagnostic tools, poor awareness of the disease, and lack of financial means for medical care as common barriers to seeking and receiving care for COPD. While there was greater access to COPD treatment in urban areas, rural populations faced more pronounced barriers in access to diagnostic equipment, following standard treatment guidelines, and training medical personnel in non-communicable disease (NCD) management and treatment. Conclusion: Our results suggest that health system challenges for the treatment of COPD may disproportionately affect rural areas in Uganda. Implementation of diagnostic and treatment guidelines and training health professionals in COPD, with a special emphasis on rural communities, will assist in addressing these barriers.