Understanding barriers to well-child visit attendance among racial and ethnic minority parents.

OBJECTIVES: To assess racial and ethnic minority parents' perceptions about barriers to well-child visit attendance. METHODS: For this cross-sectional qualitative study, we recruited parents of pediatric primary care patients who were overdue for a well-child visit from the largest safety net healthcare organization in central Massachusetts to participate in semi-structured interviews. The interviews focused on understanding potential knowledge, structural, and experiential barriers for well-child visit attendance. Interview content was inductively coded and directed content analysis was performed to identify themes. RESULTS: Twenty-five racial and ethnic minority parents participated; 17 (68%) of whom identified Spanish as a primary language spoken at home. Nearly all participants identified the purpose, significance, and value of well-child visits. Structural barriers were most cited as challenges to attending well-child visits, including parking, transportation, language, appointment availability, and work/other competing priorities. While language emerged as a distinct barrier, it also exacerbated some of the structural barriers identified. Experiential barriers were cited less commonly than structural barriers and included interactions with office staff, racial/ethnic discrimination, appointment reminders, methods of communication, wait time, and interactions with providers. CONCLUSIONS: Racial and ethnic minority parents recognize the value of well-child visits; however, they commonly encounter structural barriers that limit access to care. Furthermore, a non-English primary language compounds the impact of these structural barriers. Understanding these barriers is important to inform health system policies to enhance access and delivery of pediatric care with a lens toward reducing racial and ethnic-based inequities.

Caregiver Ratings of Toddler Pain: The Role of Caregiver Psychological Predictors.

INTRODUCTION/AIM: Young children's limited ability to self-report pain necessitates an understanding of the factors that influence pain ratings. The current paper examines the relative prediction of caregiver psychological factors and toddler pain behaviors on caregiver pain ratings post-vaccination. METHODS: One hundred fifty-six parent-toddler dyads were video recorded during pediatric vaccinations. Child pain behaviors were coded before, during, and after the needle using the Face, Legs, Activity, Cry, Consolability Scale and the Neonatal Facial Coding System). Caregivers rated their child's pain after the needle, reported pre- and post-needle worry during the visit, and completed rating scales assessing other areas of psychological functioning within 2 weeks after the appointment. Regression models were estimated to examine the relative contribution of child and caregiver factors to the prediction of caregiver pain ratings. RESULTS: The regression model predicting caregiver pain ratings from the toddlers' pain-related distress (facial activity immediately after the needle, overall pain-related behavior immediately after, 1-min and 2-min post-needle) and caregiver worry were significant (adjusted R-square = 0.21), with caregiver pre- and post-needle worry being the only significant predictors of caregiver pain ratings. CONCLUSIONS: This study outlines that although child distress behavior remains a significant influence on pain ratings during toddlerhood, when caregiver worry (pre- and post-needle) was entered into the model, they were the only significant predictors of caregiver pain ratings.

A Sierra Leone 2021 Midwifery Clinical Training Needs Assessment: A Call to Action to Augment Clinical Precepting.

Objective: Sierra Leone has one of the highest maternal mortality and infant mortality rates globally. We share findings from a Midwifery Clinical Training Needs Assessment, conducted in 2021 as a collaboration between the Government of Sierra Leone and Seed Global Health. The assessment identified existing needs and gaps in midwifery clinical training at health facilities in Sierra Leone from various stakeholders' perspectives. Methods: The descriptive needs assessment utilized mixed methods, including surveys, focus group discussions (FGDs), interviews, and reviews of maternal medical records. Results: The following showed needs and gaps in labor and delivery management; record keeping; triage processes; clinical education for students, recent graduates, and preceptors; and lack of infrastructure and resources. Conclusion: The knowledge gained from this needs assessment can further the development of midwifery clinical training programs in Sierra Leone and other low-income countries facing similar challenges. We discuss the implication of our findings.

MEASURING PATIENT EXPERIENCE OF ORAL HEALTH CARE: A CALL TO ACTION.

BACKGROUND: Surveys to measure patients' experiences of health care are common practice in general medical care to improve patient centered care. However, such questionnaires are not consistently used to capture the patient's experience of oral health care. Because patient experience is an important component of oral health care, there is an urgent need to measure it in the oral health care setting. PURPOSE: The purpose of this article is to illustrate the need for patient experience measurement in oral health care, highlight the challenges such measurement in this setting faces, and provide a set of next steps to advance care experience measurement for dental patients. BASIC PROCEDURES: We conducted a comprehensive review of the literature examining patient experience measurement in medical and oral health care. This focused on studies aimed at understanding the current measurement landscape and existing measurement tools. We also gathered additional information and perspectives through discussions with key informants and stakeholders. MAIN FINDINGS: There is a critical need for patient experience measurement in oral health care. To develop a program to measure patient experiences of oral care, the following should be done: (1) convene stakeholders and get their buy-in; (2) develop a patient experiences of oral health conceptual framework; (3) develop a survey tool that captures key aspects of patient experiences of oral health; (4) pilot the survey tool; (5) assess the survey tool...s psychometric properties; and (6) refine and finalize the survey tool. PRINCIPLE CONCLUSIONS: To advance the measurement of the quality of oral health care, we outline a stepwise methodology that captures dental patient experiences of oral health care.

Utilizing a manualized therapy to provide parallel treatment to older adults with cancer and their caregivers: A case study.

The experience of anxiety is a common and understandable reaction to a diagnosis of and treatment for cancer. Patients of any age may experience negative psychological and physical symptoms during cancer treatment; older adults with cancer simultaneously face the impact of cancer and the effects of aging. Caregivers of older adults with cancer are also vulnerable to experiencing anxiety as their loved one navigates the physical and emotional sequelae of their illness and treatment. This paper describes the use of Managing Anxiety from Cancer (MAC), a 7-session telephone-delivered manualized cognitive-behavioral intervention that includes strategies from Acceptance and Commitment Therapy and Problem-Solving Therapy, with an older woman with cancer and her adult daughter. MAC includes a variety of techniques for patients and caregivers, who are encouraged to use these strategies individually or in different combinations to manage their anxiety. This brief treatment provided a parallel experience for the participants, as the older adult patient and her caregiver were taught the same anxiety-management techniques by their individual therapists. We will discuss the benefits and drawbacks of using a manualized psychotherapy intervention in this case, as well as MAC's impact on each member of this pair and on the dyad as a unit. Both the patient and her caregiver reported experiencing benefit from their participation in MAC and identified MAC-acquired skills they planned to use in the future to manage their anxiety and improve communication. While assessment data did not reflect a decrease in anxiety, it is possible that the stress of the COVID-19 pandemic confounded these data.

An Emotion Regulation Tablet App for Middle-Aged and Older Adults at High Suicide Risk: Feasibility, Acceptability, and Two Case Studies.

OBJECTIVE: The unique features of technological applications may improve the treatment of people at risk of suicide. In this article, we present feasibility and acceptability data as well as two case studies demonstrating the use of WellPATH, a tablet app that aims to help suicidal patients during emotionally-charged situations outside of therapy sessions. The WellPATH app was part of a 12-week psychotherapy intervention (CRISP - Cognitive Reappraisal Intervention for Suicide Prevention) for middle-aged and older adults after their discharge from a suicide-related hospitalization. DESIGN: The use of WellPATH includes three stages: preparation and practice, incorporation, and actual use. MEASUREMENTS: Feasibility was measured by the overall use of WellPATH during 12 weeks, and acceptability was measured with the three items of the Client Satisfaction Questionnaire. RESULTS: Twelve study participants were administered WellPATH as part of CRISP. The results provide preliminary evidence of feasibility and acceptability of WellPATH. Study participants and therapists reported high satisfaction with WellPATH and provided feedback for future research and development. The patients in the case studies reported a reduction in negative emotions and an increase in emotion regulation (i.e., cognitive reappraisal ability) after using techniques on the WellPATH app. CONCLUSION: Our preliminary findings suggest that use of technology applications such as the WellPATH app is feasible and accepted among middle-aged and older adults at high suicide risk. Further research with an adequately powered sample is needed to further evaluate WellPATH's feasibility and accessibility, and test its efficacy with this high-risk population.

Managing Anxiety from Cancer (MAC): A pilot randomized controlled trial of an anxiety intervention for older adults with cancer and their caregivers.

OBJECTIVE: Anxiety is common in older adults with cancer (OACs) and their caregivers and is associated with poor outcomes including worse physical symptoms, poor treatment adherence and response, and longer hospitalizations. This study examined the feasibility, acceptability, adherence, and preliminary efficacy of a cognitive-behavioral therapy (CBT) intervention for OACs and their caregivers. METHOD: Patients with active cancer age 65 years and older and their caregivers were randomized to Managing Anxiety from Cancer (MAC), a seven-session CBT-based psychotherapy intervention delivered over the telephone or usual care. Patients and caregivers completed the intervention separately with licensed social workers. Self-report measures of anxiety, depression, and quality of life were administered after randomization and following intervention completion. Analyses were conducted separately for patients and caregivers and at the dyad level. Hierarchical Linear Modeling accounted for the within-dyad intraclass correlation coefficients (ICCs) by random intercepts associated with the dyads. RESULTS: Twenty-nine dyads were randomized; 28 (96.6%) patients and 26 (89.7%) caregivers completed all study procedures. Of dyads randomized to MAC, 85.7% (n = 12) of patients and caregivers completed all seven sessions. Most patients (≥50%) and over 80% of caregivers rated the overall intervention and intervention components as "moderately" to "very" helpful. MAC was associated with a greater reduction in anxiety among dyads than usual care, the effect of MAC was greater in caregivers than in patients, and improvement in patient anxiety was associated with the reduction in caregiver anxiety. However, these results did not reach statistical significance. SIGNIFICANCE OF RESULTS: This pilot study demonstrates the feasibility of MAC and suggests strategies for improving acceptability, with a focus on adherence. Furthermore, these results indicate that MAC is promising for the reduction of anxiety in OAC-caregiver dyads and may be particularly beneficial for OAC caregivers. Larger randomized controlled trials are needed to evaluate the efficacy of MAC.

Can Self-Management Improve HIV Treatment Engagement, Adherence, and Retention? A Mixed Methods Evaluation in Tanzania and Uganda.

This paper presents the evaluation results of a self-management support (SMS) initiative in Tanzania and Uganda, which used quality improvement to provide self-management counseling, nutritional support, and strengthened linkages to community-based services for highest-risk patients (those with malnutrition, missed appointments, poor adherence, high viral load, or low CD4 count). The evaluation assessed improvements in patient engagement, ART adherence, and retention. Difference-in-difference models used clinical data (n = 541 in Tanzania, 571 in Uganda) to compare SMS enrollees to people who would have met SMS eligibility criteria had they been at intervention sites. Interviews with health care providers explored experiences with the SMS program and were analyzed using codes derived deductively from the data. By end-line, SMS participants in Tanzania had significantly improved visit attendance (odds ratio 3.53, 95% confidence interval 2.15, 5.77); a non- significant improvement was seen in Uganda (odds ratio 1.62, 95% confidence interval 0.37, 7.02), which may reflect a dose-response relationship due to shorter program exposure there. Self-management can improve vulnerable patients' outcomes-but maximum gains may require long implementation periods and accompanying system-level interventions. SMS interventions require long-term investment and should be contextualized in the systems and environments in which they operate.

Barriers to HIV Treatment Adherence: A Qualitative Study of Discrepancies Between Perceptions of Patients and Health Providers in Tanzania and Uganda.

Previous qualitative studies about antiretroviral therapy (ART) adherence have largely focused on patient experiences. Less is known about the perspective of health care providers-particularly in low-income countries-who serve as gatekeepers and influencers of patients' HIV care experiences. This study explored patients' and providers' perceptions of important ART adherence determinants. Interviews were conducted at HIV treatment sites in Tanzania and Uganda, with adult patients on ART (n = 148), and with health care providers (n = 49). Patients were asked about their experiences with ART adherence, and providers were asked about their perceptions of what adherence challenges are faced by their patients. All interviews were conducted in local languages; transcripts were translated into English and analyzed using a codebook informed by the social ecological model. Themes were examined across and within countries. Adherence-related challenges were frequently reported, but patients and providers did not often agree about the reasons. Many patients cited challenges related to being away from home and therefore away from their pill supply; and, in Uganda, challenges picking up refills (access to care) and related to food sufficiency/diet. Providers also identified these access to care barriers, but otherwise focused on different key determinants (e.g., they rarely mentioned food/diet); instead, providers were more likely to mention alcohol/alcoholism, stigma, and lack of understanding about the importance of adhering. These findings suggest areas of opportunity for future research and for improving clinical care by aligning perceptions of adherence challenges, to deliver better-informed and useful ART counseling and support.

Reducing Mother-to-Child Transmission of HIV Using Quality Improvement Approaches.

Over half of mother-to-child HIV transmission (MTCT) occurs postdelivery. Keeping mother-infant pairs in care remains challenging. Health workers in 3 countries used quality improvement (QI) approaches to improve data systems, mother-infant retention, and facility-based care delivery. The number and proportion of infants with known HIV status at time of discharge from early infant diagnosis programs increased in Tanzania and Uganda. We analyzed data using statistical process control charts. Mother-to-child HIV transmission did not decrease in 15 Kenyan sites, decreased from 12.7% to 3.8% in 28 Tanzanian sites, and decreased from 17.2% to 1.5% in 10 Ugandan sites with baseline data. This improvement is likely due to the combination of option B+, service delivery improvements, and retention through QI approaches. Reaching the global MTCT elimination target and maximizing infant survival will require health systems to support mother-infant pairs to remain in care and support health workers to deliver care. Quality improvement approaches can support these changes.

Using a Multicountry Learning Network to Harvest and Rapidly Spread Implementation Knowledge across Programs Aimed to Reduce Mother-to-Child Transmission of HIV and Improve Nutrition: Perspectives and Lessons Learned for Similar Large-Scale Initiatives.

As countries pursue UNAIDS's 90-90-90 target for ending the AIDS epidemic, success is dependent on learning how to deliver effective care. We describe a learning network and mechanisms used to foster communication and sharing of ideas and results across 6 countries in the Partnership for HIV-Free Survival. The network used 2 forms of peer exchange, in-person and virtual, and a variety of knowledge management mechanisms to harvest and spread key learning. Key learning included valuable insights on how to design and convene a multicountry learning network, including top enablers of success and practical insights on the network's value. The network was instrumental in accelerating learning about improving care. Our experience shows the value of creating a quality improvement-driven, multicountry learning network to accelerate the pace of improving care systems. Government ownership and adaptation of collaborative learning efforts to the country context must be considered when designing future networks.

A 6-Country Collaborative Quality Improvement Initiative to Improve Nutrition and Decrease Mother-to-Child Transmission of HIV in Mother-Infant Pairs.

Despite advances in coverage and quality of prevention of mother-to-child transmission (PMTCT) programs, infant protection from postnatal HIV infection remains an issue in high HIV-burdened countries. We designed a quality improvement (QI) intervention-the Partnership for HIV-Free Survival (PHFS)-to improve infant survival. PHFS convened leaders in 6 sub-Saharan African nations to discover together the best strategies for implementing and scaling up existing PMTCT protocols to ensure optimal health of mother-baby pairs and HIV-free infant survival. We used 3 core technical components-rapid adaptive design, collaborative learning, and scale-up/sustainability designs-to test strategies for accelerating effective PMTCT programming in complex, resource-poor settings. Learning generated included the need for increased ownership and codesign of improvement initiatives with Ministries of Health, better integration of initiatives into existing programs, and the need to sustain QI capability throughout the system. PHFS can serve as a design prototype for future global networks aiming to accelerate improvement, learning, and results.

Applying Quality Improvement Approaches to Reduce Mother-to-Child HIV Transmission and Improve Health and Nutrition Care in Five Countries: Lessons from the Partnership for HIV-Free Survival.

The World Health Organization guidelines for treating pregnant HIV-positive women and preventing HIV transmission to infants now recommend lifelong antiretroviral treatment for pregnant and breastfeeding women. We applied quality improvement (QI) methods to support governments and facility staff to address service gaps in 5 countries under the Partnership for HIV-Free Survival (PHFS). We used 3 key strategies: break the complex problem of improving HIV-free survival into more easily implementable phases, support a national management team to oversee the project, and support facility-level staff to learn and apply QI methods to reducing mother-to-child transmission. The key results in each country were increases in data completeness and accuracy, increases in retention in care of mother-baby pairs (MBPs), increase in coverage of MBPs with appropriate services, and reduction in vertical transmission of HIV. The PHFS experience offers a model that other multicountry networks can adopt to improve service delivery and quality of care.

Problem Adaptation Therapy for Pain (PATH-Pain): A Psychosocial Intervention for Older Adults with Chronic Pain and Negative Emotions in Primary Care.

Chronic pain is highly prevalent in older adults, contributes to activity restriction and social isolation, disrupts family and interpersonal relationships, and poses a significant economic burden to society. Negative emotions such as sadness, anxiety, helplessness, and hopelessness are associated with chronic pain and contribute to poor quality of life, impaired interpersonal and social functioning, and increased disability. Psychosocial interventions for older adults with chronic pain have been historically developed for, and are almost exclusively delivered to, cognitively intact patients. Therefore, many older adults with chronic pain and comorbid cognitive deficits have limited treatment options. Our multidisciplinary team developed Problem Adaptation Therapy for Pain in Primary Care (PATH-Pain), a psychosocial intervention for older adults with chronic pain, negative emotions, and a wide range of cognitive functioning, including mild-to-moderate cognitive impairment. In the current article, we describe the principles underlying PATH-Pain, review the steps taken to adapt the original PATH protocol, outline the treatment process, and present a case illustrating its potential value.

Using adapted quality-improvement approaches to strengthen community-based health systems and improve care in high HIV-burden sub-Saharan African countries.

INTRODUCTION: Achieving long-term retention in HIV care is an important challenge for HIV management and achieving elimination of mother-to-child transmission. Sustainable, affordable strategies are required to achieve this, including strengthening of community-based interventions. Deployment of community-based health workers (CHWs) can improve health outcomes but there is a need to identify systems to support and maintain high-quality performance. Quality-improvement strategies have been successfully implemented to improve quality and coverage of healthcare in facilities and could provide a framework to support community-based interventions. METHODS: Four community-based quality-improvement projects from South Africa, Malawi and Mozambique are described. Community-based improvement teams linked to the facility-based health system participated in learning networks (modified Breakthrough Series), and used quality-improvement methods to improve process performance. Teams were guided by trained quality mentors who used local data to help nurses and CHWs identify gaps in service provision and test solutions. Learning network participants gathered at intervals to share progress and identify successful strategies for improvement. RESULTS: CHWs demonstrated understanding of quality-improvement concepts, tools and methods, and implemented quality-improvement projects successfully. Challenges of using quality-improvement approaches in community settings included adapting processes, particularly data reporting, to the education level and first language of community members. CONCLUSION: Quality-improvement techniques can be implemented by CHWs to improve outcomes in community settings but these approaches require adaptation and additional mentoring support to be successful. More research is required to establish the effectiveness of this approach on processes and outcomes of care.

Psychiatric assessment and screening for the elderly in primary care: design, implementation, and preliminary results.

INTRODUCTION: We describe the design and implementation of a psychiatric collaborative care model in a University-based geriatric primary care practice. Initial results of screening for anxiety and depression are reported. METHODS AND MATERIALS: Screens for anxiety and depression were administered to practice patients. A mental health team, consisting of a psychiatrist, mental health nurse practitioner and social worker, identified patients who on review of screening and chart data warranted evaluation or treatment. Referrals for mental health interventions were directed to members of the mental health team, primary care physicians at the practice, or community providers. RESULTS: Subjects (N=1505) comprised 38.2% of the 3940 unique patients seen at the practice during the 4-year study period. 37.1% (N=555) screened positive for depression, 26.9 % (N=405) for anxiety, and 322 (21.4%) screened positive for both. Any positive score was associated with age (p<0.033), female gender (p<0.006), and a non-significant trend toward living alone (p<0.095). 8.87% had suicidal thoughts. CONCLUSIONS: Screening captured the most affectively symptomatic patients, including those with suicidal ideation, for intervention. The partnering of mental health professionals and primary care physicians offers a workable model for addressing the scarcity of expertise in geriatric psychiatry.

Face and body: independent predictors of women's attractiveness.

Women's faces and bodies are both thought to provide cues to women's age, health, fertility, and personality. To gain a stronger understanding of how these cues are utilized, we investigated the degree to which ratings of women's faces and bodies independently predicted ratings of women's full-body attractiveness. Women came into the lab not knowing they would be photographed. In Study 1 (N = 84), we photographed them in their street clothes; in Study 2 (N = 74), we photographed women in a solid-colored two-piece swimsuit that revealed their body shape, body size, and breast size. We cropped each woman's original photo into an additional face-only photo and body-only photo; then, independent sets of raters judged women's pictures. When dressed in their original clothes, women's face-only ratings were better independent predictors of full-body attractiveness ratings than were their body-only ratings. When cues displayed in women's bodies were made conspicuous by swimsuits, ratings of faces and bodies were similarly strong predictors of full-body attractiveness ratings. Moreover, women's body mass index and waist-to-hip ratio were tied to ratings of women's body attractiveness, with waist-to-hip ratio more important among women wearing swimsuits than among women wearing their original clothes. These results suggest that perceivers attend to cues of women's health, fertility, and personality to the extent that they are visible.

What is the experience of national quality campaigns? Views from the field.

OBJECTIVE: To identify key characteristics of a national quality campaign that participants viewed as effective, to understand mechanisms by which the campaign influenced hospital practices, and to elucidate contextual factors that modified the perceived influence of the campaign on hospital improvements. DATA SOURCES: In-depth interviews, hospital surveys, and Health Quality Alliance data. STUDY DESIGN: We conducted a qualitative study using in-depth interviews with clinical and administrative staff (N = 99) at hospitals reporting strong influence (n = 6) as well as hospitals reporting limited influence (n = 6) of the Door-to-Balloon (D2B) Alliance, a national quality campaign to improve heart attack care. We analyzed these qualitative data as well as changes in hospital use of recommended strategies reported through a hospital survey and changes in treatment times using Health Quality Alliance data. DATA COLLECTION METHODS: In-depth, open-ended interviews; hospital survey. PRINCIPAL FINDINGS: Key characteristics of the national quality campaign viewed as enhancing its effectiveness were as follows: credibility of the recommendations, perceived simplicity of the recommendations, alignment with hospitals' strategic goals, practical implementation tools, and breadth of the network of peer hospitals in the D2B Alliance. Perceived mechanisms of the campaign's influence included raising awareness and influencing goals, fostering strategy adoption, and influencing aspects of organizational culture. Modifying contextual factors included perceptions about current performance and internal championship for the recommended changes. CONCLUSIONS: The impact of national quality campaigns may depend on both campaign design features and on the internal environment of participating hospitals.

Blueprint for the dissemination of evidence-based practices in health care.

Aimed at fostering the broad adoption of effective health care interventions, this report proposes a blueprint for improving the dissemination of best practices by national quality improvement campaigns. The blueprint's eight key strategies are to: 1) highlight the evidence base and relative simplicity of recommended practices; 2) align campaigns with strategic goals of adopting organizations; 3) increase recruitment by integrating opinion leaders into the enrollment process; 4) form a coalition of credible campaign sponsors; 5) generate a threshold of participating organizations that maximizes network exchanges; 6) develop practical implementation tools and guides for key stakeholder groups; 7) create networks to foster learning opportunities; and 8) incorporate monitoring and evaluation of milestones and goals. The impact of quality campaigns also depends on contextual factors, including the nature of the innovation itself, external environmental incentives, and features of adopting organizations.