"Pouring From an Empty Cup": Manifestations, Drivers, and Protective Factors of Occupational Stress Among Healthcare Providers of Trauma-Informed Care.

In the United States alone, 10 million people are affected by family and domestic violence (DV). DV survivors experience many forms of victimization, including physical, psychological, and sexual abuse resulting in trauma. The DV workforce, including healthcare providers, social workers, advocates, and other providers, utilize trauma-informed care in a variety of settings to help DV survivors heal and recover from their traumatic experiences. Given the intensity of DV work and occupational stressors associated with navigating complex survivor cases and systems of care, health and mental health professionals can experience burnout, compassion fatigue, and secondary traumatic stress. The purpose of this qualitative study was to explore how professionals in the DV workforce, including healthcare and mental health professionals, experience and mitigate occupational stress. Twenty in-depth interviews were conducted with DV professionals, who worked in medical settings like urban hospitals as well as DV shelters and rape crisis centers in Boston, MA. A semistructured interview guide was developed, and pilot tested and addressed the following topics including experiences of occupational stress, and mitigators of occupational stress. The interviews were audio recorded, transcribed, and analyzed using a thematic analysis approach. Codes were organized into themes and subthemes, which were reviewed and refined during research team discussions. Risk factors of occupational stress included caseload quantity and intensity, workplace isolation, and length of time in the field. Protective factors spanned individual, interpersonal, and organizational level factors. Participants described various strategies for mitigating occupational stress, including training, supervision, and self-care. Findings from this study have the potential to inform policies and practices among healthcare organizations that support professionals in the DV workforce who work with DV survivors.

Community-Academic Team Teaching in a CBPR Course: Lessons Learned about Course Instruction.

BACKGROUND: Community-based participatory research (CBPR) involves community and academic partners working collaboratively to understand and address local challenges. Undergraduates who engage in CBPR through a course can learn valuable research and professional skills, but we found no studies describing the experiences of community and academic partner instructors who have co-taught undergraduate CBPR courses. We describe lessons the instructors learned from collaboratively teaching one such course. LESSONS LEARNED: The lessons we include highlight how community-academic team teaching can 1) provide unique opportunities to teach and model partnership and collaboration, 2) incorporate nontraditional learning opportunities for students to practice skills and engage in content reflection, 3) be challenged by differing community and academic priorities, and 4) surface power dynamics in the classroom that should be explicitly discussed. CONCLUSIONS: Community and academic partners can successfully team teach in an undergraduate CBPR course and encourage the development of important skills that can be transferable to the real world. Focusing on offering traditional and nontraditional learning opportunities and modelling partnership and collaboration can also facilitate this. Beyond these benefits, instructors considering a model like this should be prepared to intentionally engage in discussions within and outside the classroom about respective priorities and the ways in which knowledge that is traditionally valued in academic settings can create power dynamics in the classroom. Ultimately, structural supports, such as institutional funding for community partners and consideration of benefits to community partners and organizations beyond the research itself can facilitate these types of collaborations.

Key correlates of exclusive breastfeeding at three timepoints: Evidence from Ethiopia.

Aim: To compare factors associated with exclusive breastfeeding (EBF) within 1 h of birth, within 3 days, and within the first 6 months post-birth. Methods: We used multivariate logistic regression models and data from "The Alive and Thrive Phase 2 Amhara Baseline Survey 2015" from Ethiopia (N = 3113). Results: Giving colostrum was strongly associated with EBF at all three time points, controlling for multiple confounders. Putting the baby to the breast before cleaning the baby and before cleaning the mother was significantly associated with EBF within 1 h and for the first 3 days. EBF within an hour of birth was more likely for girl babies than boy babies. Having a healthcare professional check whether the baby was sucking well was significantly associated with EBF 3 days post-birth. Conclusions: The World Health Organization recommends breastfeeding within 1 h of birth and exclusively thereafter for 6 months, which can improve health outcomes for infants and children. In Ethiopia, many factors influence breastfeeding practices, but little is known about how these factors differ at various key timepoints in the 6 months after birth. Our study provides important information on correlates of EBF at three timepoints and shows that factors that are significantly correlated with EBF vary over time. Future research should assess the potential causal links among statistically significant associations between EBF and risk factors at various times between birth and 6 months of age. Ultimately, these findings have the potential to inform areas of intervention related to promoting EBF.

Informal preparation and years of experience: Key correlates of dyslexia knowledge among Massachusetts early elementary teachers.

BACKGROUND: Dyslexia is a neurobiological condition affecting phonological processing and characterized by reading and phonological awareness difficulties. We assessed correlations between dyslexia knowledge and five independent variables among early elementary teachers in Massachusetts. METHODS: We designed a survey based on two published assessment tools and surveyed 92 early elementary teachers. Using univariate and multivariate linear regression models, we assessed the relationships among knowledge (dependent variable) and confidence, feelings of preparedness, years of teaching experience, informal education and professional development opportunities (independent variables). RESULTS: The mean knowledge score was 68 ± 14%; teachers performed best on questions about perceptions of dyslexia, classroom management/teaching strategies and some dyslexia characteristics. Informal education and years of teaching experience were consistently positively associated with knowledge. DISCUSSION AND CONCLUSIONS: Formal training and professional development opportunities may need to focus more specifically on learning disabilities and dyslexia. Teachers should also have input on professional development needs. Our findings suggest a need for additional studies on strategies to improve educator knowledge of dyslexia and assess outcomes.

"Collaboration Toward One Collective Goal": A Mixed-Methods Study of Short-Term Learning Outcomes and Long-Term Impacts Among Students Participating in an Undergraduate Community-Based Participatory Research (CBPR) Course.

Background: Research shows positive learning outcomes for students participating in service learning. However, the impacts of undergraduate student participation in Community-Based Participatory Research (CBPR) courses are minimally studied. Methods: We used a triangulation mixed-methods design approach to analyze short- and long-term (1-5 years post-course) data collected from 59 undergraduate students across 5 cohorts of a CBPR course (2014-19). Thematic analysis was used to analyze the qualitative data and descriptive statistics and frequencies were generated to analyze the quantitative data. Results: We developed five key themes based on short-term qualitative data: integration of CBPR and traditional research skills; importance of community engagement in research; identity; accountability; and collaboration. Themes from qualitative course evaluations aligned with these findings. Long-term qualitative data revealed that former students gained research knowledge, research skills, and professional skills and then applied these in other settings. This aligns with quantitative findings, where >79% of respondents reported that course participation "extensively" improved their research skills. Post-course, students still reflected on the importance of community engagement in research and reported a substantially enhanced likelihood of civic engagement. Discussion/Conclusions: Students gained critical knowledge and skills that positively impact their ability to engage in community-based work well after the end of course participation. Some students reported considering research-oriented careers and graduate programs for the first time after course participation. Collaborative learning experiences with community partners and members encouraged students to reflect on research designs that center community voices. We stress here that community partnerships require extensive cultivation, but they can create opportunities to translate findings directly back to communities and provide numerous benefits to undergraduate students. We hope that our findings provide the information needed to consider pilot testing practice-based CBPR courses in a variety of public health training contexts.

Addressing Youth-Focused Research Questions in a Community Context: Collecting and Integrating Mixed Methods Data at Multiple Ecological Levels with the PhotoStories Project.

Research seeking to understand and improve social conditions for marginalized youth would benefit from merging complex mixed methods research designs emphasizing multilevel data and participatory-social justice principles. We contribute to mixed methods research by introducing a multilevel, participatory-social justice mixed methods design that accomplishes this task and by illustrating its real-world application via PhotoStories, a multistage study aimed at understanding youths' community-based experiences and emotional well-being. During the project's three phases (preparation, training, and dissemination) we obtained and integrated quantitative and qualitative data at multiple ecological levels. Additionally, we examined youth perceptions about their participation, an important outcome given our participatory-social justice focus. We also provide lessons learned and recommendations for investigators seeking to use similar approaches for youth-focused research.

Barriers, facilitators, and disparities in retention for adolescents in treatment for substance use disorders: a qualitative study with treatment providers.

BACKGROUND: Retention in substance use treatment is one of the strongest predictors of improved outcomes among adolescents, making retention an important goal of treatment. We examined treatment providers' perspectives on barriers and facilitators to treatment retention among adolescents, and their views on contributors to racial/ethnic disparities in retention including ways to address disparities. METHODS: Semi-structured interviews were conducted with 19 providers at state-licensed detoxification, residential, and outpatient facilities serving adolescents for substance use disorders in Massachusetts. Interviews were coded by at least two independent coders. RESULTS: Providers identified barriers and facilitators at the policy/systems, facility, family, and client levels. Some of the barriers included insurance limits on sessions/length of stay and low reimbursement (policy/systems), staff turnover (facility), low family engagement (family), and low internal motivation (client). Some facilitators mentioned were support from state's substance use agency (policy/systems), flexibility with meeting location (facility), family participation (family), and high internal motivation and presence of external motivators (client). Barriers that contributed to racial/ethnic disparities included lower socio-economic status, language barriers, and mistrust. Having bilingual/bicultural staff and multi-lingual materials, and facilitating transportation were identified as strategies for reducing disparities in treatment retention. CONCLUSIONS: It is critical that adolescents who access substance use services remain and complete treatment and that there is equity in treatment retention. Provider perspectives in factors associated with retention can inform the development of comprehensive interventions and policies to help improve retention and reduce disparities.

Establishing Teams: How Does It Change Practice Configuration, Size, and Composition?

Little is known about how practices reorganize when transitioning from traditional practice organization to team-based care. We compared practice-level (1) configuration as well as practice- and team-level (2) size and (3) composition, before and after establishing teams. We employed a pre-/poststudy using personnel lists of 1571 to 1711 staff (eg, job licenses, titles, and team assignment) and practice manager surveys. All personnel (physician and nonphysician) worked within 18 Massachusetts academic primary care practices participating in a 2-year learning collaborative aimed at establishing team-based care. We found that establishing team-based care can involve changing practice configurations and composition without substantially changing practice size.

African American Women's Involvement in Promoting Informed Decision-Making for Prostate Cancer Screening Among Their Partners/Spouses.

Routine prostate cancer screening is not recommended but African American men who are at higher risk for the disease should be offered the opportunity for shared decision-making with their health-care providers. This qualitative study sought to better understand the potential role of women in educating their male spouses/partners about prostate cancer screening. Nine focus groups were conducted ( n = 52). Women were recruited from a variety of community venues. Those eligible were African American and married to or in a partnership with an African American male age ≥ 45. Women provide numerous types of support to their male partners in an effort to facilitate participation in preventive health care. While women agreed that they would like to educate their partners about prostate cancer screening, they had little information about screening guidelines or the potential harms and limitations. The current findings suggest that women are eager information-seekers and can disseminate information to men and facilitate their efforts to make more informed decisions about prostate cancer screening. Women should be included in educational interventions for to promote informed decision-making for prostate cancer screening.

Strategies to Build Readiness in Community Mobilization Efforts for Implementation in a Multi-Year Teen Pregnancy Prevention Initiative.

PURPOSE: This paper describes an assessment of community readiness to implement a community-wide teen pregnancy prevention initiative, Youth First, and presents strategies used to enhance this readiness as informed by the assessment. METHODS: Twenty-five community stakeholder interviews were conducted to assess four domains of readiness: (1) attitudes, perception, and knowledge of teen pregnancy; (2) perceived level of readiness; (3) resources, existing and current efforts; and (4) leadership. Interview transcripts were coded and analyzed to identify key themes. RESULTS: Stakeholders acknowledged teen pregnancy as an issue but lacked contextual information. They also perceived the community as ready to address the issue and recognized some organizations already championing efforts. However, many key players were not involved, and ongoing data collection to assess teen pregnancy and prevention efforts was limited. Though many stakeholders were ready to engage in teen pregnancy prevention efforts, they required additional information and training to appropriately address the issue. CONCLUSIONS: In response to the assessment findings, several strategies were applied to address readiness and build Youth First partners' capacity to implement the community-wide initiative. Thus, to successfully implement community-wide prevention efforts, it is valuable to assess the level of community readiness to address health issues.

Team dynamics, clinical work satisfaction, and patient care coordination between primary care providers: A mixed methods study.

BACKGROUND: Team-based care is essential for delivering high-quality, comprehensive, and coordinated care. Despite considerable research about the effects of team-based care on patient outcomes, few studies have examined how team dynamics relate to provider outcomes. PURPOSE: The aim of this study was to examine relationships among team dynamics, primary care provider (PCP) clinical work satisfaction, and patient care coordination between PCPs in 18 Harvard-affiliated primary care practices participating in Harvard's Academic Innovations Collaborative. METHODOLOGY: First, we administered a cross-sectional survey to all 548 PCPs (267 attending clinicians, 281 resident physicians) working at participating practices; 65% responded. We assessed the relationship of team dynamics with PCPs' clinical work satisfaction and perception of patient care coordination between PCPs, respectively, and the potential mediating effect of patient care coordination on the relationship between team dynamics and work satisfaction. In addition, we embedded a qualitative evaluation within the quantitative evaluation to achieve a convergent mixed methods design to help us better understand our findings and illuminate relationships among key variables. FINDINGS: Better team dynamics were positively associated with clinical work satisfaction and quality of patient care coordination between PCPs. Coordination partially mediated the relationship between team dynamics and satisfaction for attending clinicians, suggesting that higher satisfaction depends, in part, on better teamwork, yielding more coordinated patient care. We found no mediating effects for resident physicians. Qualitative results suggest that sources of satisfaction from positive team dynamics for PCPs may be most relevant to attending clinicians. PRACTICE IMPLICATIONS: Improving primary care team dynamics could improve clinical work satisfaction among PCPs and patient care coordination between PCPs. In addition to improving outcomes that directly concern health care providers, efforts to improve aspects of team dynamics may also help resolve critical challenges in workforce planning in primary care.

Enhancing Adolescent Reproductive Health Services: Assessment of Health Care Practices in Holyoke and Springfield, MA Engaged in the Youth First Initiative.

Health care practices can play a key role in reducing teen pregnancies, though current health care systems do not adequately meet adolescents' reproductive health needs. To address this gap, Youth First, a Centers for Disease Control and Prevention funded, community-wide initiative in Holyoke and Springfield (Massachusetts) established partnerships with nine local health care practices to increase adolescent access to health services. However, we had limited knowledge about their reproductive health services and policies. To address this gap, assessments were conducted with staff using structured interviews and surveys to inform targeted efforts to enhance the quality and youth friendliness of adolescent reproductive health services. Findings revealed that many of the youth-friendly services best practices recommended by the CDC were not routinely implemented by all health care practices. Findings from this assessment can be used to support health care practices to facilitate widespread adoption of best practices related to meeting adolescents' reproductive health needs.

A mixed-methods approach to understanding water use and water infrastructure in a schistosomiasis-endemic community: case study of Asamama, Ghana.

BACKGROUND: Surface water contaminated with human waste may transmit urogenital schistosomiasis (UGS). Water-related activities that allow skin exposure place people at risk, but public health practitioners know little about why some communities with access to improved water infrastructure have substantial surface water contact with infectious water bodies. Community-based mixed-methods research can provide critical information about water use and water infrastructure improvements. METHODS: Our mixed-methods study assessed the context of water use in a rural community endemic for schistosomiasis. RESULTS: Eighty-seven (35.2 %) households reported using river water but not borehole water; 26 (10.5 %) reported using borehole water but not river water; and 133 (53.8 %) households reported using both water sources. All households are within 1 km of borehole wells, but tested water quality was poor in most wells. Schistosomiasis is perceived by study households (89.3 %) to be a widespread problem in the community, but perceived schistosomiasis risk fails to deter households from river water usage. Hematuria prevalence among schoolchildren does not differ by household water use preference. Focus group data provides context for water preferences. Demand for improvements to water infrastructure was a persistent theme; however, roles and responsibilities with respect to addressing community water and health concerns are ill-defined. CONCLUSIONS: Collectively, our study illustrates how complex attitudes towards water resources can affect which methods will be appropriate to address schistosomiasis.

Pediatric provider processes for behavioral health screening, decision making, and referral in sites with colocated mental health services.

OBJECTIVE: Validated behavioral health (BH) screens are recommended for use at well-child visits. This study aimed to explore how pediatricians experience and use these screens for subsequent care decisions in primary care. METHODS: The study took place at 4 safety net health centers. Fourteen interviews were conducted with pediatricians who were mandated to use validated BH screens at well-child visits. Interview questions focused on key domains, including clinic BH context, screening processes, assessment of screening scores, and decision making about referral to mental health services. Qualitative analysis used the Framework Approach. RESULTS: A variety of themes emerged: BH screens were well accepted and valued for the way they facilitated discussion of mental health issues. However, screening results were not always used in the way that instrument designers intended. Providers' beliefs about the face validity of the instruments, and their observations about performance of instruments, led to discounting scored results. As a result, clinical decisions were made based on a variety of evidence, including individual item responses, parent or patient concerns, and perceived readiness for treatment. Additionally, providers, although interested in expanding their mental health discussions, perceived a lack of time and of their own skills to be major obstacles in this pursuit. CONCLUSIONS: Screens act as important prompts to stimulate discussion of BH problems, but their actual scored results play a variable role in problem identification and treatment decisions. Modifications to scheduling policies, additional provider training, and enhanced collaboration with mental health professionals could support better BH integration in pediatric primary care.

Assessing research interest and capacity in community health centers.

OBJECTIVE: Community health centers (CHCs) have great potential to participate in the development of evidence-based primary care but face obstacles to engagement in clinical translational research. METHODS: To understand factors associated with CHC interest in building research infrastructure, Harvard Catalyst and the Massachusetts League of Community Health Centers conducted an online survey of medical directors in all 50 Massachusetts CHC networks. RESULTS: Thirty-two (64%) medical directors completed the survey representing 126 clinical sites. Over 80% reported that their primary care providers (PCPs) were slightly to very interested in future clinical research and that they were interested in building research infrastructure at their CHC. Frequently cited barriers to participation in research included financial issues, lack of research skills, and lack of research infrastructure. In bivariate analyses, PCP interest in future clinical research and a belief that involvement in research contributed to PCP retention were significantly associated with interest in building research infrastructure. CONCLUSION: CHCs critical role in caring for vulnerable populations ideally positions them to raise relevant research questions and translate evidence into practice. Our findings suggest a high interest in engagement in research among CHC leadership. CTSAs have a unique opportunity to support local CHCs in this endeavor.

Provider's perspectives on building research and quality improvement capacity in primary care: a strategy to improve workforce satisfaction.

OBJECTIVES: Safety-net populations are underrepresented in research and quality improvement (QI) studies despite the fact that safety-net providers are uniquely positioned to engage in translational research. This study aimed to understand the current level of interest in, experience with, predicted career satisfaction associated with, and barriers experienced in conducting research and QI among primary care providers (PCPs) at 18 safety-net practices in the Boston, Massachusetts area. METHODS: The Harvard Catalyst Safety-net Infrastructure Initiative partnered with staff at a large academic public hospital system, including 15 primary care sites, to develop and administer an online survey. This survey was then adapted and administered at three other academically affiliated community health centers. RESULTS: Of the 260 providers surveyed, 136 (52%) responded. Nearly 80% reported interest in conducting either QI projects or clinical research and 95% of them believed it would enhance their career satisfaction. However, 63% did not report prior experience or training in research or QI and 93% reported at least one barrier to engagement. CONCLUSION: While supporting safety-net PCPs' engagement in research and/or QI may improve career satisfaction there are numerous barriers that must be addressed to achieve this goal.

Community capacity building and sustainability: outcomes of community-based participatory research.

BACKGROUND: For communities, the value of community-based participatory research (CBPR) is often manifested in the outcomes of increased capacity and sustainable adoption of evidence-based practices for social change. Educational opportunities that promote discourse between community and academic partners can help to advance CBPR and better define these outcomes. OBJECTIVES: This paper describes a community-academic conference to develop shared definitions of community capacity building and sustainability related to CBPR and to identify obstacles and facilitators to both. METHODS: "Taking It to the Curbside: Engaging Communities to Create Sustainable Change for Health" was planned by five Clinical Translational Science Institutes and four community organizations. After a keynote presentation, breakout groups of community and academic members met to define community capacity building and sustainability, and to identify facilitators and barriers to achieving both. Groups were facilitated by researcher-community partner teams and conversations were recorded and transcribed. Qualitative analysis for thematic content was conducted by a subset of the planning committee. RESULTS: Important findings included learning that (1) the concepts of capacity and sustainability were considered interconnected; (2) partnership was perceived as both a facilitator and an outcome of CBPR; (3) sustainability was linked to "transfer of knowledge" from one generation to another within a community; and (4) capacity and sustainability were enhanced when goals were shared and health outcomes were achieved. CONCLUSIONS: Community capacity building and sustainability are key outcomes of CBPR for communities. Co-learning opportunities that engage and mutually educate both community members and academics can be useful strategies for identifying meaningful strategies to achieve these outcomes.

Community-based participatory research skills and training needs in a sample of academic researchers from a clinical and translational science center in the Northeast.

PURPOSE: To determine the community-based participatory research (CBPR) training interests and needs of researchers interested in CBPR to inform efforts to build infrastructure for conducting community-engaged research. METHOD: A 20-item survey was completed by 127 academic health researchers at Harvard Medical School, Harvard School of Public Health, and Harvard affiliated hospitals. RESULTS: Slightly more than half of the participants reported current or prior experience with CBPR (58 %). Across all levels of academic involvement, approximately half of the participants with CBPR experience reported lacking skills in research methods and dissemination, with even fewer reporting skills in training of community partners. Regardless of prior CBPR experience, about half of the respondents reported having training needs in funding, partnership development, evaluation, and dissemination of CBPR projects. Among those with CBPR experience, more than one-third of the participants wanted a mentor in CBPR; however only 19 % were willing to act as a mentor. CONCLUSIONS: Despite having experience with CBPR, many respondents did not have the comprehensive package of CBPR skills, reporting a need for training in a variety of CBPR skill sets. Further, the apparent mismatch between the need for mentors and availability in this sample suggests an important area for development.

Neighborhood influences on perceived social support among parents: findings from the project on human development in Chicago neighborhoods.

BACKGROUND: Social support is frequently linked to positive parenting behavior. Similarly, studies increasingly show a link between neighborhood residential environment and positive parenting behavior. However, less is known about how the residential environment influences parental social support. To address this gap, we examine the relationship between neighborhood concentrated disadvantage and collective efficacy and the level and change in parental caregiver perceptions of non-familial social support. METHODOLOGY/PRINCIPAL FINDINGS: The data for this study came from three data sources, the Project on Human Development in Chicago Neighborhoods (PHDCN) Study's Longitudinal Cohort Survey of caregivers and their offspring, a Community Survey of adult residents in these same neighborhoods and the 1990 Census. Social support is measured at Wave 1 and Wave 3 and neighborhood characteristics are measured at Wave 1. Multilevel linear regression models are fit. The results show that neighborhood collective efficacy is a significant (ß = .04; SE = .02; p = .03), predictor of the positive change in perceived social support over a 7 year period, however, not of the level of social support, adjusting for key compositional variables and neighborhood concentrated disadvantage. In contrast concentrated neighborhood disadvantage is not a significant predictor of either the level or change in social support. CONCLUSION: Our finding suggests that neighborhood collective efficacy may be important for inducing the perception of support from friends in parental caregivers over time.

Investigating the myth of the "model minority": a participatory community health assessment of Chinese and Vietnamese adults.

Despite the persistent belief that Asians are the "model minority" there is accumulating evidence of health concerns within Asian subgroups. In this study, we implemented a cross-sectional participatory community health assessment in an urban city in Massachusetts, to understand differences and similarities in demographics, health and healthcare access in Chinese and Vietnamese adults. We gathered qualitative data from community stakeholders to inform the development of a community health assessment tool. The tool elicited information on healthcare access, health status, behavioral health and chronic disease history and treatment. Healthcare access issues and poor health status, particularly among Chinese participants and mental health symptomotology in both groups were areas of concern. These findings revealed important health concerns in two Asian ethnic groups. Studies are needed to better understand these concerns and inform programs and policies to improve health outcomes in these Asian ethnic groups.