Using a Patient Educational Video to Improve Knowledge of Maternal Mortality Warning Signs: A Randomized Controlled Trial.

OBJECTIVE: To determine whether a community-informed, language-concordant postpartum video education campaign, developed with community input, improves patients' knowledge of warning signs for postpartum maternal mortality (infection, hemorrhage, hypertensive disorders, and postpartum depression) compared with routine discharge procedures. METHODS: A single-center, investigator-blinded, parallel-group randomized controlled trial of postpartum individuals who delivered at a large, urban, tertiary care hospital. Eligible participants were enrolled and completed a baseline knowledge questionnaire. After delivery, they were randomized to routine discharge education (control) or routine education plus video education (intervention). After discharge education, patient knowledge was again assessed in both groups before participants left the hospital. The primary outcome was the percentage of participants who showed improvement in their knowledge, measured by the number of correct questionnaire responses after education compared with their baseline, assessed as a binary outcome. A sample size of 150 (75 per group) was planned to detect a 25% absolute increase in the frequency of the primary outcome. RESULTS: From July to August 2022, 296 participants were screened and 200 were randomized (100 per group). Eighty-two percent of participants had college or graduate education, and 71.5% had commercial insurance. There was no significant difference in baseline characteristics. There was no statistically significant difference in the percentage of participants who improved their scores between the baseline and posteducation questionnaires (64.5% vs 50.0%, P =.09). However, the median posteducation questionnaire total score was significantly higher in the video education group (14 [interquartile range 12-15] vs 13 [interquartile range 12-14], P =.003). In addition, they more frequently reported that video education was "very helpful" (83.9% vs 72.5%, P =.23) and that they were "very satisfied" with their education (86.1% vs 75.5%, P =.29). CONCLUSION: Enhanced postpartum education through a novel video did not result in a statistically significant difference in frequency of improved score on the posteducation questionnaires but was associated with increased satisfaction with care. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT05159726.

What will it take? Using an implementation research framework to identify facilitators and barriers in implementing a school-based referral system for sexual health services.

BACKGROUND: Across the United States, sexually transmitted infections and unintended pregnancy rates are alarmingly high among youth. Schools, due to their proximity and access to youth, can increase student access to sexual health services (SHS) by creating referral systems (RS) to link students to school- and community-based SHS. From 2013 to 2018, the Centers for Disease Control and Prevention's Division of Adolescent and School Health funded 17 Local Education Agencies (LEA) to partner with priority schools and stakeholders to develop and implement RS to increase student access to SHS. Cicatelli Associates Inc. (CAI) was funded to provide capacity-building to LEA. In 2016-2017, CAI conducted case studies at two LEA, both large and urban sites, but representing different geographical and political contexts, to elucidate factors that influence RS implementation. METHODS: Nineteen LEA and community-based healthcare (CBH) staff were interviewed in the Southeastern (n = 9) and Western U.S. (n = 10). Key constructs (e.g., leadership engagement, resources, state and district policies) across the five domains of the Consolidated Framework for Implementation Research (CFIR) framework guided the methodology and analysis. Qualitative data was analyzed using the Framework Method and contextual factors and themes that led to RS implementation were identified. RESULTS: Interviewees strongly believed that school-based RS can decrease STI, HIV and unintended pregnancy and increase students' educational attainment. We identified the following contextual key factors that facilitate successful implementation and integration of an RS: enforcing state and district policies, strong LEA and CBH collaboration, positive school culture towards adolescent health, knowledgeable and supportive staff, leveraging of existing resources and staffing structures, and influential district and school building-level leadership and champions. Notably, this case study challenged our initial assumptions that RS are easily implemented in states with comprehensive SHS policies. Rather, our conversations revealed how districts and local-level policies can have significant impact and influence to impede or promote those policies. CONCLUSIONS: Through the use of the CFIR framework, the interviews identified important contextual factors and themes associated with LEAs' implementation barriers and facilitators. The study's results present key recommendations that other LEA can consider to optimize integration of RS-related evidence-based practices, systems, and policies in their districts.

From policy to practice in the Affordable Care Act: Training center for New York State's health insurance programs.

BACKGROUND: The United States currently faces the large, logistical undertaking of enrolling millions of Americans into a complex Affordable Care Act (ACA) system within a short period of time. One way states have addressed this implementation challenge is through the development of consumer assistance programs. In these programs, health care professionals-known as "Assistors"-are trained in insurance enrollment services to help consumers navigate the complex application and plan selection process, with the ultimate goal of optimizing enrollment rates. ORGANIZATIONAL CONTEXT: Cicatelli Associates Inc. (CAI), a non-profit capacity building organization, has served as the Statewide Training Center for New York's Health Insurance Program Initiative since 2013, before the ACA Marketplace roll-out occurred. This article presents a narrative of CAI's experiences and promising practices related to training and developing of the Assistor workforce in New York State (NYS). SOLUTIONS IDENTIFIED THROUGH TRAINING AND DEVELOPMENT: By the end of the second enrollment period (February 2015), NYS trained and certified over 11,000 Assistors (1); CAI trained fifteen percent of this total workforce. As a result of this intensive workforce training effort, NYS observed extremely high rates of facilitated enrollment, and overall success with the roll-out process. LESSONS FROM THE FIELD: Through this initiative, CAI has garnered key insights for other organizations that engage in similar work, as well as state policymakers considering how to integrate and bolster the Assistor programs in their states. These lessons include: the necessity of ensuring that Assistors are armed with all technical concepts and messages; ensuring that Assistors are motivated to work through a change process; the constructive feedback process that can occur when these Assistors directly communicate issues to the state; and the transformation of public opinion that can occur when Assistors provide good customer service and can effectively promote statewide and federal ACA policies and benefits.

'Our only resource': Perspectives and Recommendations of Rural African American Youth on Adapting Sexual Health and Risk Reduction Interventions.

Recent studies have documented disproportionately high rates of sexually transmitted infections (STIs), HIV, and births among adolescents in rural areas of the United States. Despite this, the majority of sexual health education programs and interventions were developed for adolescents in metropolitan areas, and may not be appropriate or relevant for rural youth. The present study investigates the perspectives of 73 African American youth in rural Georgia who participated in a cognitive-behavioral intervention to reduce sexual risk behaviors, in an effort to understand how the intervention and ones similar to it may be tailored to better meet the needs of rural adolescents. Findings highlight the importance of incorporating diverse teaching and recruitment strategies into interventions when delivering them to rural youth, as well as the need to expand education and risk reduction efforts. Additional research is warranted to understand better how to meet the sexual health education needs of rural youth.

Improving completion rates for client intake forms through Audio Computer-Assisted Self-Interview (ACASI): results from a pilot study with the Avon Breast Health Outreach Program.

This study compares rates of completion of client intake forms (CIFs) collected via three interview modes: audio computer-assisted self-interview (ACASI), face-to-face interview (FFI), and self-administered paper-based interview (SAPI). A total of 303 clients served through the Avon Breast Health Outreach Program (BHOP) were sampled from three U.S. sites. Clients were randomly assigned to complete a standard CIF via one of the three interview modes. Logistic regression analyses demonstrated that clients were significantly more likely to complete the entire CIF via ACASI than either FFI or SAPI. The greatest observed differences were between ACASI and SAPI; clients were almost six times more likely to complete the CIF via ACASI as opposed to SAPI (AOR = 5.8, p < .001). We recommend that where feasible, ACASI be utilized as an effective means of collecting client-level data in healthcare settings. Adoption of ACASI in health centers may translate into higher completion rates of intake forms by clients, as well as reduced burden on clinic staff to enter data and review intake forms for completion.

Studying sudden and unexpected infant deaths in a time of changing death certification and investigation practices: evaluating sleep-related risk factors for infant death in New York City.

We describe an approach for quantifying and characterizing the extent to which sudden and unexpected infant deaths (SUIDs) result from unsafe sleep environments (e.g., prone position, bedsharing, soft bedding); and present data on sleep-related infant deaths in NYC. Using a combination of vital statistics and medical examiner data, including autopsy and death scene investigation findings, we analyzed any death due to accidental threat to breathing (ATB) (ICD-10 W75 & W84), and deaths of undetermined intent (UND) (Y10-Y34) between 2000 and 2003 in NYC for the presence of sleep-related factors (SRF). Homicide deaths were excluded as were SIDS, since in NYC SIDS is not a certification option if environmental factors were possibly contributors to the death. All 19 ATB and 69 (75%) UND had SRFs as per the OCME investigation. Black infants and infants born to teen mothers had higher SRF death rates for both ATB and UND deaths. Bedsharing was the most common SRF (53%-ATB; 72%-UND deaths); the majority of non-bedsharing infants were found in the prone position (60%-ATB; 78%-UND deaths). We found a high prevalence of SRFs among ATB and UND deaths. This is the first local study to illustrate the importance of knowing how SUIDs are certified in order to ascertain the prevalence of infant deaths with SRFs. Advancing the research requires clarity on the criteria used by local medical examiners to categorize SUIDs. This will help jurisdictions interpret their infant mortality statistics, which in turn will improve education and prevention efforts.

Working with interpreters: an interactive Web-based learning module.

OBJECTIVE: Medical students are presented with unique challenges when they care for patients with limited English proficiency. Students must learn a complex set of skills needed to care for patients across cultural and language barriers and to understand the impact of their own attitudes and beliefs about caring for these patients. We developed and piloted a multimedia interactive Web-based module aimed at teaching students effective strategies for working with interpreters and diverse patient populations, and at raising their awareness of important legal, ethical, and cultural issues. DESCRIPTION: First the learner completes a 37-multiple-choice-question (MCQ) pre-test that assesses attitudes, factual knowledge, and ability to analyze written clinical scenarios relevant to the module's content. Learners are then shown a series of professionally produced video vignettes, which reflect diverse patient populations, interpreters, and effectiveness of interpretation strategies (e.g., a Russian-speaking woman with chest pain whose daughter interprets, a medical student interpreting for a Chinese-speaking man using herbal medication, a Haitian woman told of an abnormal mammogram through a trained simultaneous interpreter). In each case, learners submit short answers to on-screen questions analyzing the effectiveness of the interpretation strategies demonstrated. Immediate feedback is given comparing student responses with those of experts. At any time during the module, the learners may view video commentary by legal, ethics, and cultural experts, or access a glossary and Web site links. Students conclude the module by again taking the MCQ test. A final screen compares their pre- and post-MCQ test responses and shows best answers, allowing them to assess their learning. The learners also complete a survey, providing personal cultural information and feedback on the module. DISCUSSION: All 160 first-year medical students completed the module and evaluated its effectiveness this year. On average, students improved by 20% on the MCQ post-test and 86% of the students were satisfied with the learning experience and acquired new knowledge. As a result of their participation in the module, students examined their own cultural and linguistic backgrounds and made the following comments: "I am interested in exploring the way my own culture and cultural biases could impact my working with patients from other cultures"; "This module has opened my eyes to the fears and concerns of immigrants who do not speak English." Therefore, this pilot of the module effectively imparted guidelines for, and raised awareness of, medical interpreting. The most common critique of the module was that as a result of technical difficulties, it was time-consuming. A more rigorous evaluation is planned for the next academic year. We are also working to enrich and enhance the module for more experienced clinicians (GME and CME). As a complementary educational tool, the Internet has the advantages of allowing students to work at their own paces, view engaging video clips, and participate in interactive learning with immediate feedback and self-assessment.