Understanding critical factors associated with integration of community health workers into health and hospital systems.

Community health worker (CHW) models have been shown to improve health behaviors and health outcomes and reduce cost, particularly among low-income underserved populations. Consequently, health systems are increasingly employing CHWs to provide health services in clinical environments. A growing body of the literature suggests that effective integration of CHWs within the healthcare system is important to achieve the desired outcomes, but the question of how to achieve effective integration is less clear. This study seeks to explore the integration of CHWs within a large state university health system to identify factors critical to the effective integration of CHWs into the clinical care environment. We conducted a qualitative descriptive multiple embedded case study of the University of Illinois at Chicago's Hospital and Health Science System (UI Health). The embedded subunits of analysis were teams within the UI Health System that currently employ CHWs to assist with the provision of clinical care or services to patients. Data were collected via semi-structured interviews and document review. In total, six sub-units were enrolled, and 17 interviews were conducted with CHWs (n = 9), and administrators or healthcare providers (n = 8). Fourteen factors related to effective CHW integration were identified and organized in four categories: individual, team, organization, and community. Findings suggest that in addition to commonly recognized elements of effective CHW models including training, supervision, and the presence of a champion, programs must consider the organizational context in which the program is positioned as well as the ways in which both CHWs and the organization engage with communities served. This research can serve as a roadmap for health systems that seek to integrate CHWs within healthcare services and can be used to promote best practice in CHW integration.

Population Health Management Tools to Support School-Based Oral Health Partnerships and Address Disparities.

BACKGROUND: Dental caries (cavities) experience is prevalent in US children, and national data show rates to be increasing among young children. Disparities are found for those in the low-income and non-Hispanic Black and Hispanic/Latinx groups. Use of caries prevention, specifically dental sealants, is low, even among school-based programs. CONTRIBUTIONS TO THEORY: A population health management (PHM) framework may support targeted school-based case management to reduce oral health disparities. PHM-oriented tools were applied to a school-based oral health intervention and developed into a conceptual model. From 2014 to 2019, Chicago-based Oral Health Forum (OHF) developed a case management intervention in schools, utilizing PHM tools. Through programmatic and school-based partnerships, the PHM tools informed intervention to incorporate community-based organizations, case management staffing, oral health education, targeted community outreach, and Community Dental Health Coordinators' training. CONCLUSIONS: Through a PHM framework, school-based oral health partnerships targeting high-need children was implemented. Use of PHM tools in school-based health programs should be considered in other high caries schools.

Understanding the relationship between care team perceptions about CHWs and CHW integration within a US health system, a qualitative descriptive multiple embedded case study.

BACKGROUND: Community health workers (CHW) have grown in prominence within the healthcare sector, yet there is no clear consensus regarding a CHW's role, purpose, and value within health systems. This lack of consensus has the potential to affect how CHWs are perceived, utilized, and ultimately integrated within the healthcare sector. This research examines clinical care teams that currently employ CHWs to (1) understand how members of the care team perceive CHWs' purpose and value, and (2) consider how perceptions of CHWs are related to CHW integration within health care teams. METHODS: Researchers conducted a qualitative descriptive multiple embedded case study at the University of Illinois at Chicago's Hospital and Health Science System (UI Health). The embedded subunits of analysis were teams within UI Health that are currently employing CHWs to assist with the provision of clinical care or services to patients. Data were collected via semi-structured interviews and document review. RESULTS: In total, 6 sub-units were enrolled to participate, and 17 interviews were conducted with CHWs (n = 9), and administrators or health care providers (n = 8). Reported perceptions of CHWs were inconsistent across respondents. CHWs roles were not always understood, and the CHW's purpose and value was perceived differently by different members of the care team. Moreover, evaluation metrics did not always capture CHWs' value to the health care system. In some cases, care teams were more aligned around a shared understanding of the CHW's roles and purpose within the care team. When perceptions regarding CHWs were both positive and aligned, respondents reported higher levels of integration within the healthcare system. CONCLUSIONS: Alignment in a care team's perception of a CHW's role, purpose, and value within the health system could play an important role in the integration of CHWs within healthcare teams.

Framing the Integration of Community Health Workers Into Health Care Systems Along Health Care and Community Spectrums.

Research calls for community health worker (CHW) integration within health systems, yet there is no agreement regarding what CHW integration is or guidance for how it can be achieved. This study examines factors associated with CHW integration in community and health care settings using a qualitative descriptive multiple-embedded case study of CHW teams at the University of Illinois at Chicago. Data were collected via semistructured interviews/document review and analyzed using thematic coding and quantitative content analysis. Factors associated with higher clinical integration included culture, communication, protocols, and training while higher community integration was associated with accessibility, relationships, and empathy.

Postpubertal spermatogonial stem cell transplantation restores functional sperm production in rhesus monkeys irradiated before and after puberty.

BACKGROUND: Cancer treatment of prepubertal patients impacts future fertility due to the abolition of spermatogonial stem cells (SSCs). In macaques, spermatogenesis could be regenerated by intratesticular transplantation of SSCs, but no studies have involved cytotoxic treatment before puberty and transplantation after puberty, which would be the most likely clinical scenario. OBJECTIVES: To evaluate donor-derived functional sperm production after SSC transplantation to adult monkeys that had received testicular irradiation during the prepubertal period. MATERIALS AND METHODS: We obtained prepubertal testis tissue by unilaterally castrating six prepubertal monkeys and 2 weeks later irradiated the remaining testes with 6.9 Gy. However, because spermatogenic recovery was observed, we irradiated them again 14 months later with 7 Gy. Three of the monkeys were treated with GnRH-antagonist (GnRH-ant) for 8 weeks. The cryopreserved testis cells from the castrated testes were then allogeneically transplanted into the intact testes of all monkeys. Tissues were harvested 10 months later for analyses. RESULTS: In three of the six monkeys, 61%, 38%, and 11% of the epididymal sperm DNA were of the donor genotype. The ability to recover donor-derived sperm production was not enhanced by the GnRH-ant pretreatment. However, the extent of filling seminiferous tubules during the transplantation procedure was correlated with the eventual production of donor spermatozoa. The donor epididymal spermatozoa from the recipient with 61% donor contribution were capable of fertilizing rhesus eggs and forming embryos. Although the transplantation was done into the rete testis, two GnRH-ant-treated monkeys, which did not produce donor-derived epididymal spermatozoa, displayed irregular tubular cords in the interstitium containing testicular spermatozoa derived from the transplanted donor cells. DISCUSSION AND CONCLUSION: The results further support that sperm production can be restored in non-human primates from tissues cryopreserved prior to prepubertal and post-pubertal gonadotoxic treatment by transplantation of these testicular cells after puberty into seminiferous tubules.

A Cross-sectional Survey of Enteral Feeding Tube Placement and Gastric Residual Aspiration Practices: Need for an Evidence-Based Clinical Practice Guideline.

BACKGROUND: Preterm infants routinely require enteral feeding via nasogastric or orogastric tubes as an alternative to oral feeding to meet their nutritional needs. Anecdotal evidence suggests variations in practice related to correct tube placement and assessment of feed intolerance. PURPOSE: To determine the current practices of enteral feeding tube placement confirmation and gastric residual (GR) aspiration of neonatal clinicians in Australia. METHODS: A cross-sectional online survey comprising 24 questions was distributed to nursing and medical health professionals working in Australian neonatal care units through 2 e-mail listservs made available by professional organizations. FINDINGS: The survey was completed by 129 clinicians. A single method was practiced by 50% of the clinicians in confirming tube placement, and most common practice was assessing the pH of GR aspirate. The majority of respondents (96%) reported that they relied on GR aspiration and clinical signs to determine feeding tolerance and subsequent decisions such as ceasing or decreasing feeds. However, the frequency of aspiration, the amount and color of aspirate considered to be normal/abnormal, and decisions on whether to replace gastric aspirate or whether aspiration should be performed during continuous tube feeding varied. IMPLICATION FOR PRACTICE: This study demonstrated considerable variability in clinical practice for enteral feeding tube placement confirmation and GR aspiration despite most respondents reporting using a unit-based clinical practice guideline. Our study findings highlight the need for not only developing evidence-based practice guidelines for safe and consistent clinical practice but also ensuring that these guidelines are followed by all clinicians. IMPLICATION FOR RESEARCH: Further research is needed to establish evidence-based methods both for enteral feeding tube placement confirmation and for the assessment of feeding intolerance during tube feeding. In addition, the reasons why evidence-based methods are not followed must be investigated.

Restoration of functional sperm production in irradiated pubertal rhesus monkeys by spermatogonial stem cell transplantation.

BACKGROUND: In male pre-pubertal cancer patients, radiation and chemotherapy impact future fertility by eradication of spermatogonial stem cells (SSCs). In macaques, spermatogenesis could be regenerated by intratesticular transplantation of SSCs, but only a small percentage of spermatozoa produced were of donor origin. Transient hormone suppression with a GnRH antagonist (GnRH-ant) enhanced spermatogenic recovery from transplanted SSCs. OBJECTIVES: To evaluate donor-derived and endogenous spermatogenic recovery after SSC transplantation into irradiated monkeys and to test whether hormone suppression around the time of transplantation facilitates spermatogenic recovery. MATERIALS AND METHODS: Testes of 15 adult rhesus monkeys were irradiated with 7 Gy and 4 months later transplanted, to one of the testes, with cryopreserved testicular cells containing SSCs from unrelated monkeys. Monkeys were either treated with GnRH-ant for 8 weeks before transplantation, GnRH-ant from 4 weeks before to 4 weeks after transplantation, or with no GnRH-ant. Tissues were harvested 10 months after transplantation. RESULTS: Two of the 15 monkeys, a control and a pre-transplantation GnRH-ant-treated, showed substantially higher levels of testicular spermatogenesis and epididymal sperm output in the transplanted side as compared to the untransplanted. Over 84% of epididymal spermatozoa on the transplanted side had the donor genotype and were capable of fertilizing eggs after intracytoplasmic sperm injection forming morulae of the donor paternal origin. Low levels of donor spermatozoa (~1%) were also identified in the epididymis of three additional monkeys. Transplantation also appeared to enhance endogenous spermatogenesis. DISCUSSION AND CONCLUSION: We confirmed that SSC transplantation can be used for restoration of fertility in male cancer survivors exposed to irradiation as a therapeutic agent. The success rate of this procedure, however, is low. The success of filling the tubules with the cell suspension, but not the GnRH-ant treatment, was related to the level of colonization by transplanted cells.

Evaluating the implementation of cervical cancer screening programs in low-resource settings globally: a systematized review.

PURPOSE: Cervical cancer disproportionately burdens low-resource populations where access to quality screening services is limited. A greater understanding of sustainable approaches to implement cervical cancer screening services is needed. METHODS: We conducted a systematized literature review of evaluations from cervical cancer screening programs implemented in resource-limited settings globally that included a formal evaluation and intention of program sustainment over time. We categorized the included studies using the continuum of implementation research framework which categorizes studies progressively from "implementation light" to more implementation intensive. RESULTS: Fifty-one of 13,330 initially identified papers were reviewed with most study sites in low-resource settings of middle-income countries (94.1%) ,while 9.8% were in low-income countries. Across all studies, visual inspection of the cervix with acetic acid (58.8%) was the most prevalent screening method followed by cytology testing (39.2%). Demand-side (client and community) considerations were reported in 86.3% of the articles, while 68.6% focused scientific inquiry on the supply side (health service). Eighteen articles (35.3%) were categorized as "Informing Scale-up" along the continuum of implementation research. CONCLUSIONS: The number of cervical cancer screening implementation reports is limited globally, especially in low-income countries. The 18 papers we classified as Informing Scale-up provide critical insights for developing programs relevant to implementation outcomes. We recommend that program managers report lessons learnt to build collective implementation knowledge for cervical cancer screening services, globally.

Impact of Natural Disasters on Health Outcomes and Cancer Among Older Adults.

There is growing evidence that older adults exposed to natural disasters are at disproportionate risk for adverse health events such as all-cause mortality, injury, hospital admissions, stroke, displacement, cardiopulmonary distress, stress-related mental health problems, and exacerbation of chronic illnesses. Typically, analyses of the health consequences of natural disasters focus only on the populations impacted for the duration and immediate aftermath of the disaster. With few exceptions, the long-term effects of natural disasters on older adult health have not been examined. This article describes the potential consequences of exposure to natural disasters that contribute to cancer and disruption of cancer care treatment systems for older adults. It is argued that exposures to floods and wildfires in particular present an underestimated threat to the onset and/or progression of cancer and cancer care management in older adults. We propose that these impacts should be examined not only from an emergency preparedness perspective during the event but also from a public health focus that prospectively assesses risks for cancer and other health disparities. Recommendations for comprehensive longitudinal risk assessment and emergency preparedness models that address the full impact of natural disasters on the health and well-being of vulnerable, at risk, older adults are offered.

Autologous grafting of cryopreserved prepubertal rhesus testis produces sperm and offspring.

Testicular tissue cryopreservation is an experimental method to preserve the fertility of prepubertal patients before they initiate gonadotoxic therapies for cancer or other conditions. Here we provide the proof of principle that cryopreserved prepubertal testicular tissues can be autologously grafted under the back skin or scrotal skin of castrated pubertal rhesus macaques and matured to produce functional sperm. During the 8- to 12-month observation period, grafts grew and produced testosterone. Complete spermatogenesis was confirmed in all grafts at the time of recovery. Graft-derived sperm were competent to fertilize rhesus oocytes, leading to preimplantation embryo development, pregnancy, and the birth of a healthy female baby. Pending the demonstration that similar results are obtained in noncastrated recipients, testicular tissue grafting may be applied in the clinic.

Differentiation of primate primordial germ cell-like cells following transplantation into the adult gonadal niche.

A major challenge in stem cell differentiation is the availability of bioassays to prove cell types generated in vitro are equivalent to cells in vivo. In the mouse, differentiation of primordial germ cell-like cells (PGCLCs) from pluripotent cells was validated by transplantation, leading to the generation of spermatogenesis and to the birth of offspring. Here we report the use of xenotransplantation (monkey to mouse) and homologous transplantation (monkey to monkey) to validate our in vitro protocol for differentiating male rhesus (r) macaque PGCLCs (rPGCLCs) from induced pluripotent stem cells (riPSCs). Specifically, transplantation of aggregates containing rPGCLCs into mouse and nonhuman primate testicles overcomes a major bottleneck in rPGCLC differentiation. These findings suggest that immature rPGCLCs once transplanted into an adult gonadal niche commit to differentiate towards late rPGCs that initiate epigenetic reprogramming but do not complete the conversion into ENO2-positive spermatogonia.

Donor spermatogenesis in de novo formed seminiferous tubules from transplanted testicular cells in rhesus monkey testis.

STUDY QUESTION: Can transplanted primate testicular cells form seminiferous tubules de novo, supporting complete spermatogenesis? SUMMARY ANSWER: Cryopreserved testicular cells from a prepubertal monkey can reorganize in an adult monkey recipient testis forming de novo seminiferous tubular cords supporting complete spermatogenesis. WHAT IS KNOWN ALREADY: De novo morphogenesis of testicular tissue using aggregated cells from non-primate species grafted either subcutaneously or in the testis can support spermatogenesis. STUDY DESIGN, SIZE, DURATION: Two postpubertal rhesus monkeys (Macaca mulatta) were given testicular irradiation. One monkey was given GnRH-antagonist treatment from 8 to 16 weeks after irradiation, while the other received sham injections. At 16 weeks, cryopreserved testicular cells from two different prepubertal monkeys [43 × 106 viable (Trypan-blue excluding) cells in 260 µl, and 80 × 106 viable cells in 400 µl] were transplanted via ultrasound-guided injections to one of the rete testis in each recipient, and immune suppression was given. The contralateral testis was sham transplanted. Testes were analyzed 9 months after transplantation. PARTICIPANTS/MATERIALS, SETTING, METHODS: Spermatogenic recovery was assessed by testicular volume, weight, histology and immunofluorescence. Microsatellite genotyping of regions of testicular sections obtained by LCM determined whether the cells were derived from the host or transplanted cells. MAIN RESULTS AND THE ROLE OF CHANCE: Transplanted testis of the GnRH-antagonist-treated recipient, but not the sham-treated recipient, contained numerous irregularly shaped seminiferous tubular cords, 89% of which had differentiating germ cells, including sperm in a few of them. The percentages of donor genotype in different regions of this testis were as follows: normal tubule, 0%; inflammatory, 0%; abnormal tubule region, 67%; whole interior of abnormal tubules, >99%; adluminal region of the abnormal tubules, 92%. Thus, these abnormal tubules, including the enclosed germ cells, were derived de novo from the donor testicular cells. LARGE SCALE DATA: Not applicable. LIMITATIONS, REASONS FOR CAUTION: The de novo tubules were observed in only one out of the two monkeys transplanted with prepubertal donor testicular cells. WIDER IMPLICATIONS OF THE FINDINGS: These findings may represent a promising strategy for restoration of fertility in male childhood cancer survivors. The approach could be particularly useful in those exposed to therapeutic agents that are detrimental to the normal development of the tubule somatic cells affecting the ability of the endogenous tubules to support spermatogenesis, even from transplanted spermatogonial stem cells. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by research grants P01 HD075795 from Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD/NIH) to K.E.O and Cancer Center Support Grant P30 CA016672 from NCI/NIH to The University of Texas MD Anderson Cancer Center. The authors declare that they have no competing interests.

DDX4-EGFP transgenic rat model for the study of germline development and spermatogenesis.

Spermatogonial stem cells (SSC) are essential for spermatogenesis and male fertility. In addition, these adult tissue stem cells can be used as vehicles for germline modification in animal models and may have application for treating male infertility. To facilitate the investigation of SSCs and germ lineage development in rats, we generated a DEAD-box helicase 4 (DDX4) (VASA) promoter-enhanced green fluorescent protein (EGFP) reporter transgenic rat. Quantitative real-time polymerase chain reaction and immunofluorescence confirmed that EGFP was expressed in the germ cells of the ovaries and testes and was absent in somatic cells and tissues. Germ cell transplantation demonstrated that the EGFP-positive germ cell population from DDX4-EGFP rat testes contained SSCs capable of establishing spermatogenesis in experimentally infertile mouse recipient testes. EGFP-positive germ cells could be easily isolated by fluorescence-activated cells sorting, while simultaneously removing testicular somatic cells from DDX4-EGFP rat pup testes. The EGFP-positive fraction provided an optimal cell suspension to establish rat SSC cultures that maintained long-term expression of zinc finger and BTB domain containing 16 (ZBTB16) and spalt-like transcription factor 4 (SALL4), two markers of mouse SSCs that are conserved in rats. The novel DDX4-EGFP germ cell reporter rat described here combined with previously described GCS-EGFP rats, rat SSC culture and gene editing tools will improve the utility of the rat model for studying stem cells and germ lineage development.

Implementing visual cervical cancer screening in Senegal: a cross-sectional study of risk factors and prevalence highlighting service utilization barriers.

BACKGROUND: Senegal ranks 15th in the world in incidence of cervical cancer, the number one cause of cancer mortality among women in this country. The estimated participation rate for cervical cancer screening throughout Senegal is very low (6.9% of women 18-69 years old), especially in rural areas and among older age groups (only 1.9% of women above the age of 40 years). There are no reliable estimates of the prevalence of cervical dysplasia or risk factors for cervical dysplasia specific to rural Senegal. The goals of this study were to estimate the prevalence of cervical dysplasia in a rural region using visual inspection of the cervix with acetic acid (VIA) and to assess risk factors for cervical cancer control. PATIENTS AND METHODS: We conducted a cross-sectional study in which we randomly selected 38 villages across the Kédougou region using a three-stage clustering process. Between October 2013 and March 2014, we collected VIA screening results for women aged 30-50 years and cervical cancer risk factors linked to the screening result. RESULTS: We screened 509 women; 5.6% of the estimated target population (9,041) in the region. The point prevalence of cervical dysplasia (positive VIA test) was 2.10% (95% confidence interval [CI]: 0.99-3.21). Moreover, 287 women completed the cervical cancer risk factor survey (56.4% response rate) and only 38% stated awareness of cervical cancer; 75.9% of the screened women were less than 40 years of age. CONCLUSION: The overall prevalence of dysplasia in this sample was lower than anticipated. Despite both overall awareness and screening uptake being less than expected, our study highlights the need to address challenges in future prevalence estimates. Principally, we identified that the highest-risk women are the ones least likely to seek screening services, thus illustrating a need to fully understand demand-side barriers to accessing health services in this population. Targeted efforts to educate and motivate older women to seek screenings are needed to sustain an effective cervical cancer screening program.

Developing the Evidence Base to Inform Best Practice: A Scoping Study of Breast and Cervical Cancer Reviews in Low- and Middle-Income Countries.

BACKGROUND: Breast and cervical cancers have emerged as major global health challenges and disproportionately lead to excess morbidity and mortality in low- and middle-income countries (LMICs) when compared to high-income countries. The objective of this paper was to highlight key findings, recommendations, and gaps in research and practice identified through a scoping study of recent reviews in breast and cervical cancer in LMICs. METHODS: We conducted a scoping study based on the six-stage framework of Arskey and O'Malley. We searched PubMed, Cochrane Reviews, and CINAHL with the following inclusion criteria: 1) published between 2005-February 2015, 2) focused on breast or cervical cancer 3) focused on LMIC, 4) review article, and 5) published in English. RESULTS: Through our systematic search, 63 out of the 94 identified cervical cancer reviews met our selection criteria and 36 of the 54 in breast cancer. Cervical cancer reviews were more likely to focus upon prevention and screening, while breast cancer reviews were more likely to focus upon treatment and survivorship. Few of the breast cancer reviews referenced research and data from LMICs themselves; cervical cancer reviews were more likely to do so. Most reviews did not include elements of the PRISMA checklist. CONCLUSION: Overall, a limited evidence base supports breast and cervical cancer control in LMICs. Further breast and cervical cancer prevention and control studies are necessary in LMICs.