Mixed-methods process evaluation of a respiratory-culture diagnostic stewardship intervention.

OBJECTIVE: To conduct a process evaluation of a respiratory culture diagnostic stewardship intervention. DESIGN: Mixed-methods study. SETTING: Tertiary-care pediatric intensive care unit (PICU). PARTICIPANTS: Critical care, infectious diseases, and pulmonary attending physicians and fellows; PICU nurse practitioners and hospitalist physicians; pediatric residents; and PICU nurses and respiratory therapists. METHODS: This mixed-methods study was conducted concurrently with a diagnostic stewardship intervention to reduce the inappropriate collection of respiratory cultures in mechanically ventilated children. We quantified baseline respiratory culture utilization and indications for ordering using quantitative methods. Semistructured interviews informed by these data and the Consolidated Framework for Implementation Research (CFIR) were then performed, recorded, transcribed, and coded to identify salient themes. Finally, themes identified in these interviews were used to create a cross-sectional survey. RESULTS: The number of cultures collected per day of service varied between attending physicians (range, 2.2-27 cultures per 100 days). In total, 14 interviews were performed, and 87 clinicians completed the survey (response rate, 47%) and 77 nurses or respiratory therapists completed the survey (response rate, 17%). Clinicians varied in their stated practices regarding culture ordering, and these differences both clustered by specialty and were associated with perceived utility of the respiratory culture. Furthermore, group "default" practices, fear, and hierarchy were drivers of culture orders. Barriers to standardization included fear of a missed diagnosis and tension between practice standardization and individual decision making. CONCLUSIONS: We identified significant variation in utilization and perceptions of respiratory cultures as well as several key barriers to implementation of this diagnostic test stewardship intervention.

A Community Capitals Framework for Identifying Rural Adaptation in Maternal-Child Home Visiting.

OBJECTIVE: To understand how maternal and child home-visiting programs are adapted, enhanced, and expanded to meet the unique needs of rural communities. DESIGN: We explored factors shaping the role of home visiting with data from a 2013-2015 statewide evaluation of Maternal, Infant, and Early Childhood Home Visiting-funded programs. Features unique to a rural experiences were mapped onto the Community Capitals Framework. SETTING: Individual, semistructured interviews were conducted at 11 of 38 home-visiting sites across Pennsylvania. PARTICIPANTS: Program administrators, home visitors, and clients. MAIN OUTCOME MEASURE: Program adaptation. RESULTS: Our analysis represents 150 interviews with 11 program sites serving 14 counties. We document how rural home-visiting programs address community-wide limitations to maternal and child health by adapting program content to better meet the needs of families in rural areas. Data demonstrate how rural home-visiting program's provision of economic and social services reach beyond maternal child health care, building the capacity of individual families and the broader community. CONCLUSIONS: Home-visiting programs should be viewed as a vehicle for improving community well-being beyond health outcomes. These programs have become an integral part of our public health framework and should be leveraged as such.

Integrating the Built and Social Environment into Health Assessments for Maternal and Child Health: Creating a Planning-Friendly Index.

Environmental and community context earliest in the life course have a profound effect on life-long health outcomes. Yet, standard needs assessments for maternal and child health (MCH) programs often overlook the full range of influences affecting health in-utero and early childhood. To address this, we developed a methodology for assessing community risk in MCH based on six domains integrating 66 indicators across community, environment, socioeconomic indicators, and MCH outcomes. We pilot this methodology in Pennsylvania, and share examples of how local governments, planners, and public health officials across the geographic spectrum can integrate this data into community planning for improved maternal and child health.

Predictors of adherence to secondary preventive medication in stroke patients.

OBJECTIVE: The purpose of this study is to identify factors which predict adherence in stroke survivors. DESIGN: This is a longitudinal study where 180 stroke survivors were assessed 1 year after their first ischaemic stroke. The relationship between adherence and illness and medication beliefs was tested at baseline (time 1) and again 5-6 weeks later (time 2). MAIN OUTCOME MEASURES: The main outcome measures used in this study are Medication Adherence Report Scale and urinary salicylate levels. RESULTS: Four variables predicted time 1 poor adherence: (1) younger age, (2) increased specific concerns about medications, (3) reduced cognitive functioning and (4) low perceived benefit of medication. Three out of these four variables were again predictive of time 2 adherence and accounted for 24% of the variance: (1) younger age, (2) increased specific concerns about medications and (3) low perceived benefit of medication. The urinary salicylate assay failed to differentiate between patients taking and not taking aspirin. CONCLUSION: Interventions to improve adherence should target patients' beliefs about their medication.

Adherence to medication in stroke survivors: a qualitative comparison of low and high adherers.

OBJECTIVES: The aim of this study was to investigate factors that may explain variance in adherence to medication in stroke patients. Design. A qualitative comparison of high and low adherers to medication. METHODS: Thirteen participants, selected from a sample of 180 stroke survivors because they self-reported the lowest adherence to medication regimes, were matched with 13 reporting maximal adherence. All took part in semi-structured qualitative interviews. RESULTS: Thematic analysis revealed that those with poor adherence to medication reported both intentional and non-intentional non-adherence. Two main themes emerged: the importance of stability of a medication routine and beliefs about medication and treatment. High adherers reported remembering to take their medication and seeking support from both family and health professionals. They also had a realistic understanding of the consequences of non-adherence, and believed their medicine did them more good than harm. Low adherers reported forgetting their medication, sometimes intentionally not taking their medication and receiving poor support from medical staff. They disliked taking their medication, had limited knowledge about the medication rationale or intentions, and often disputed its benefits. CONCLUSIONS: Our findings suggest that appropriate medication and illness beliefs coupled with a stable medication routine are helpful in achieving optimal medication adherence in stroke patients. Interventions designed to target both intentional and non-intentional adherence may help maximize medication adherence in stroke patients.