Recommendations from an expert panel of health professionals regarding a gestational diabetes risk reduction intervention for American Indian/Alaska Native Teens.

BACKGROUND: American Indian/Alaska Native (AI/AN) adolescents are at higher risk for gestational diabetes (GDM), type 2 diabetes, and pregnancy complications than the general population. OBJECTIVE: To inform cultural adaptation of a validated evidence-based intervention (VEBI) originally designed to deliver preconception counseling and diabetes education to non-AI/AN teens with diabetes. DESIGN: Qualitative data were collected using focus group and individual interview methods with health care professionals and experts (n = 16) in AI/AN health, GDM, adolescent health, and/or mother-daughter communication. A semistructured discussion guide elicited responses about provision of care for AI/AN girls at risk for GDM, experience with successful programs for AI/AN teens, comfort of mother/daughter dyads in talking about diabetes and reproductive health and reactions to video clips and booklet selections from the VEBI. All interviews were recorded and transcribed verbatim, and data analysis included inductive coding and identification of emergent themes. RESULTS: Providers felt teens and their moms would be comfortable talking about the VEBI topics and that teens who did not feel comfortable talking to their mom would likely rely on another adult female. Participants suggested including: AI/AN images/motifs, education with a community focus, and avoiding directive language. Concerns included: socioeconomic issues that affect AI/AN people such as: food and housing insecurity, abuse, and historical trauma. CONCLUSIONS: Perspectives from these participants have been used to guide the development of a culturally tailored GDM risk reduction program for AI/AN girls. This program will be available to health care providers who serve the AI/AN population.

Testing a model of health-related quality of life in women living with HIV infection.

PURPOSE: The purpose of this secondary analysis was to test Ferrans et al.'s (J Nurs Scholarsh 37(4):336-342, 2005) revised model of health-related quality of life (HRQoL) (2005) modified from the Wilson and Cleary (J Am Med Assoc 273(1):59-65, 1995) model on women living with HIV. The primary aim was to test this model, examining the relations among the five central components (biological function, symptoms, functional status, general health perceptions, and HRQoL). The secondary aim was to explore the individual (age, children, race, marital status, education) and environmental (HIV-related stigma, social support) characteristics that may impact the main components of the model. METHODS: This study employed a cross-sectional correlational design using baseline data from 178 women living with HIV/AIDS who participated in one of the two independent randomized controlled trials designed to enhance HIV medication adherence. Path analysis using structural equation modeling was used to examine the hypothesized multivariate relations proposed in the revised Wilson and Cleary (J Am Med Assoc 273(1):59-65, 1995) model of HRQoL. RESULTS: While the revised model did not fit, exploratory post hoc modified models with a path from depressive symptoms to overall general health had an adequate model fit. Women with lower depressive symptoms (r = -.457, p < .01), lower HIV-related stigma (r = -.462, p < .01), higher social support (r = .413, p < .01), higher physical functioning (r = .350, p < .01), and higher general health perceptions (r = .537, p < .01) had higher overall HRQoL. CONCLUSIONS: The results of this study have the potential to assist healthcare professionals in improving HRQoL for women living with HIV/AIDS.

Healthcare providers' perspectives on expedited partner therapy for chlamydia: a qualitative study.

OBJECTIVES: Expedited partner therapy (EPT) effectively reduces rates of reinfection with chlamydia and increases the number of partners treated for the infection. Healthcare provider (HCP) provision of EPT is low. The objective of this qualitative study was to understand HCP views and opinions regarding the use of EPT in a state where EPT is permissible but underused. METHODS: Using a purposive sampling strategy to include diverse HCPs who treat young women at risk for chlamydia, 23 semistructured, in-depth interviews were conducted between October and December 2013. The interviews included questions about knowledge, attitudes, experiences with, and barriers and facilitators regarding the use of EPT. RESULTS: Many respondents report using EPT and believe the practice is beneficial for their patients. Most providers were unaware of their colleagues' practices and had limited knowledge regarding institutional policies around EPT. HCPs noted a variety of barriers, such as fear of liability, confusion around the legal status of EPT and not being able to counsel patients' partners that make routine use of this practice a challenge. Facilitators of EPT include speaking on the phone with patients' partners and establishing legislation enabling EPT. CONCLUSIONS: This is the first study to qualitatively examine HCPs' perspectives on EPT in the USA. Barriers to EPT, including concerns about counselling patients' partners and the legal status of EPT, can be overcome. EPT recommendations could include the use of phone calls as part of their guidelines. Changing EPT legislation at the state level in the USA is an important factor to facilitate EPT use.

The Experiences of American Indian Participants and Site Coordinators in a Gestational Diabetes Risk Reduction Trial.

Gestational diabetes mellitus is the most common complication of pregnancy and contributes to increased risk for type 2 diabetes in both the mother and offspring. We developed and evaluated a gestational diabetes risk reduction and preconception counseling program, Stopping GDM (SGDM), for American Indian females. The purpose of this study is to examine the experiences of American Indian mother-daughter dyad participants and the site coordinators who facilitated the SGDM randomized controlled trial to inform program revisions. We engaged mother-daughter dyads (n = 22 dyads) and site coordinators (n = 6) in focus group interviews. Four themes emerged: (1) SGDM sparked valuable quality conversation for dyads; (2) gestational diabetes risk factors and risk reduction was new information for most dyads; (3) all trial sites experienced challenges to recruitment and engagement; and (4) study-improvement recommendations. These findings will be used to enhance SGDM to decrease adverse intergenerational health impacts of gestational diabetes in American Indian communities.

Exploring Why Birth Center Clients Choose Hospitalization for Labor and Birth.

OBJECTIVE: To identify demographic and clinical factors associated with birth center clients electing hospitalization for labor and birth and to explore the timing and rationale for elective hospitalization via health records. DESIGN: A secondary analysis of multiyear data from a quality assurance project at a single birth center. We compared two subsamples-birth center preference group and hospital preference group-and described the apparent rationale for transfers among clients in the latter group. SETTING: A single freestanding birth center where all midwives have admitting privileges at a local hospital and can accompany labor transfers. PARTICIPANTS: All cases included in the analytic sample represent women with low-risk pregnancies who were eligible for birth center birth. The birth center preference group represents clients planning to give birth at the center, and the hospital preference group consists of clients who elected for hospitalization. MEASUREMENTS: Relevant demographic and clinical information was provided for the entire analytic sample and was matched with available data collected systematically by birth center staff via chart review. The data set also included anonymous responses to an e-mailed questionnaire from clients identified by birth center staff. RESULTS: Approximately 56.1% (N = 1,155) of the cases in the data set were eligible for comparative analysis. The birth center preference and hospital preference groups included 899 (77.8%) and 256 (22.2%) individuals, respectively. In the hospital preference group, Black clients (n = 23), those who were publicly insured (n = 49), and primiparas (n = 101) were significantly overrepresented. Chart review data and questionnaire responses highlighted insurance restrictions, family preferences, pain relief options, and postpartum care as influential factors among members of the hospital preference subsample. CONCLUSION: The present analysis shows associations between certain individual characteristics and elective hospitalization during labor for birth center clients. Health record data and questionnaire responses indicated a variety of reasons for electing hospitalization, illustrating the complexity of clients' decision-making during pregnancy and birth.

Reducing risk for gestational diabetes among American Indian and Alaska Native teenagers: Tribal leaders' recommendations.

OBJECTIVE: To elicit feedback from tribal leaders and American Indian/Alaska Native (AI/AN) health system administrators as a national stakeholder perspective to inform the development of a gestational diabetes mellitus (GDM) risk reduction and preconception counseling intervention for AI/AN teenagers at high risk for GDM. METHODS: A semi-structured focus group interview guide was developed by both principal investigators and qualitative methods experts. Using open-ended questions about the Reproductive-health Education and Awareness of Diabetes in Youth for Girls (READY-Girls) booklet and video clips, AI/AN health care system administrators and elected tribal leaders attending the 2015 National Indian Health Board Conference in Washington, DC, made recommendations on adaptation for an AI/AN audience. The focus group was recorded, transcribed verbatim, and analyzed by two researchers using an inductive coding technique with constant comparison method as supported by the grounded theory approach. RESULTS: Recommendations from the 12 participants included: (1) the best ways to communicate with AI/AN teenagers, (2) the importance of parental, family, and community education and engagement to support AI/AN teenagers in GDM risk reduction, and (3) building on traditional AI/AN cultural values and practices, while accommodating differences between tribes and regions. CONCLUSION: Findings from this focus group were used to inform the iterative development of a GDM risk reduction and preconception counseling intervention for AI/AN teenagers.

Stopping Gestational Diabetes in American Indian and Alaska Native Girls: Nutrition as a Key Component to Gestational Diabetes Risk Reduction.

BACKGROUND: American Indian and Alaska Native (AI/AN) women have a higher risk of gestational diabetes mellitus (GDM) and subsequent diagnosis of diabetes than do non-Hispanic White women. Healthy eating is key to weight management both prior to pregnancy and between pregnancies and can reduce the risk of developing GDM. Our research team developed an innovative preconception counseling and diabetes risk-reduction program, which includes nutrition and weight-management principles and is culturally tailored for adolescent AI/AN women. The program is entitled Stopping Gestational Diabetes Mellitus (SGDM). OBJECTIVE: The purpose of this article is to examine nutrition-related information collected as a part of the formative qualitative research conducted for the development of a preconception counseling and gestational diabetes risk-reduction program, SGDM. METHODS: This in-depth secondary analysis explored the original qualitative data from the needs assessment for SGDM program development. Participants included AI/AN women with a history of GDM (n = 5); AI/AN girls at risk of GDM (n = 14), and their mothers (n = 11), health care providers, and health administrators who care for AI/AN girls (n = 16); AI/AN elected leaders; and Indian health system administrators (n = 12). All focus groups and interviews were reanalyzed utilizing the following research question: "How do key stakeholders discuss food and/or nutrition in terms of gestational diabetes risk reduction for AI/AN adolescent girls?" RESULTS: Three primary nutrition themes emerged: 1) AI/AN women were aware of healthy nutrition, healthy weight gainduring pregnancy, and healthy nutrition for people with type 2 diabetes, but these principles were not linked to reducing the risk of GDM; 2) participants expressed the need for education on the role of nutrition and weight management in GDM risk reduction; 3) participants shared challenges of healthful eating during and before pregnancy for AI/AN women. CONCLUSIONS: These stakeholders' comments informed the development of the nutrition components of SGDM.

Using quantitative and qualitative approaches to understand racial disparities in adult vaccination.

BACKGROUND: One proposed explanation for the persistence of racial disparities in adult immunizations is that minority patients receive primary care at practices that differ substantively from practices where white patients receive care. This study used both quantitative and qualitative methods to assess physician and practice factors contributing to disparities in a sample of inner-city, urban, and suburban practices in low to moderate income neighborhoods. METHODS: Pneumococcal polysaccharide vaccine (PPV) and influenza vaccination rates were determined from medical record review in a sample of 2021 elderly (aged > or = 65 years) patients. Their physicians were surveyed about office systems for adult immunizations and structured observations of practice physical features, and operations were conducted. Case studies of practices with lowest and highest rates and the largest racial disparities are presented. RESULTS: Overall, weighted PPV vaccination rate was 60%, but rates differed significantly by race (65.8% for whites vs 36.5% for minorities, P < .001 by stratified Cochran-Mantel-Haenszel test). Two of 6 minority panels had PPV rates less than 20%. Overall, weighted influenza vaccination rate, as measured by receipt of the vaccine in 3 of the 5 most recent seasons, was 51.9%, but rates also differed significantly by race (55.6% for whites vs 36.2% for minorities, P < .03, by stratified Cochran-Mantel-Haenszel test). CONCLUSIONS: Low rates in 2 minority panels, racial disparity between minorities and whites in mixed panels, and between-panel variation in rates contributed to the overall differences in vaccination rates by race.

Intimate partner violence, partner notification, and expedited partner therapy: a qualitative study.

Over one-third of women experience intimate partner violence (IPV) in their lifetime. IPV increases the risk of infection and re-infection with sexually transmitted infections (STIs). The extent to which health care providers consider IPV when recommending partner notification and expedited partner therapy is unknown. The objective of this qualitative study was to understand health care providers' views on IPV and STIs when recommending partner treatment to patients with chlamydia. Using a purposive sampling strategy to include health care providers who treat young women at risk for chlamydia, 23 semi-structured, in-depth interviews were conducted. While some health care providers expressed concern for their patients' safety and believed assessing for IPV was needed before provision of expedited partner therapy, nearly a third had not considered the links between IPV and STIs. Strategies used by health care providers to assess for IPV did not include inquiry about specific behaviours related to IPV, STI risk, and sexual coercion. Many health care providers understand the risk for IPV in the setting of STI treatment, yet a significant portion of those interviewed failed to recognise the link between IPV and STIs. Provider education is necessary to increase knowledge and implement more effective inquiry and counselling about IPV to more safely recommend expedited partner therapy.

Assessing Perceived Challenges to Laboratory Testing at a Malawian Referral Hospital.

Adequate laboratory infrastructure in sub-Saharan Africa is vital for tackling the burden of infectious diseases such as human immunodeficiency virus and acquired immune deficiency syndrome, malaria, and tuberculosis, yet laboratories are ill-integrated into the diagnostic and care delivery process in low-resource settings. Although much of the literature focuses on disease-specific challenges around laboratory testing, we sought to identify horizontal challenges to the laboratory testing process through interviews with clinicians involved in the diagnostic process. Based on 22 interviews with physicians, nurses, clinical officers, medical students, and laboratory technicians, technologists and supervisors, we identified 12 distinct challenges in the areas of staff, materials, workflow, and the blood bank. These challenges underscore the informational challenges that compound more visible resource shortages in the laboratory testing process, which lend themselves to horizontal strengthening efforts around the diagnostic process.

Knowledge and beliefs about influenza, pneumococcal disease, and immunizations among older people.

OBJECTIVES: Despite the burden of disease caused by influenza and pneumococcus, immunization rates are moderate and have not reached national goals set for 2010. This study's objective was to identify patient knowledge, attitudes, and beliefs that serve as facilitators of and barriers to influenza and pneumococcal vaccination. DESIGN: A survey conducted in 2000 by computer-assisted telephone interviewing. SETTING: To encounter a broad spectrum of patients and healthcare systems, we sampled patients at inner-city health centers, Department of Veterans Affairs outpatient clinics, and rural and suburban practices. PARTICIPANTS: Inclusion criteria were patients aged 66 and older and an office visit after September 30, 1998. MEASUREMENTS: Responses to questionnaire. RESULTS: Overall, 1,007 (82%) interviews were completed among 1,234 people contacted by phone. Vaccination against pneumococcal disease was significantly related to being able to accurately describe one or more classic symptoms of pneumonia (P =.05). Vaccination against influenza and pneumococcal disease was significantly related to belief that vaccination was the best way to prevent these diseases (P <.001). The unvaccinated reported that they felt they were not likely to contract influenza and that they did not know they needed the pneumococcal vaccine. Access was not related to vaccination status. CONCLUSIONS: Educational campaigns to increase vaccination rates among older adults should focus on symptoms of, risk for, and severity of influenza and pneumococcal diseases and encouraging physicians to recommend the vaccines to their patients.

Development of the Barkin Index of Maternal Functioning.

BACKGROUND: Maternal functional status is important to capture in the 12 months after childbirth, as this period marks a critical window for both mother and child. In most cases, mothers are the primary caregivers and are, therefore, responsible for the majority of the work related to infant care tasks, such as feeding, diaper changes, and doctor's appointments. Additionally, the quality of mother-child interaction in the year after childbirth affects child development. To date, postpartum functioning has exacted scarce coverage, with only one instrument claiming to measure the concept explicitly. This necessitated the development of the Barkin Index of Maternal Functioning (BIMF), which was designed to measure functioning in the year after childbirth. METHODS: Three focus groups comprised of 31 new mothers were held to elicit women's concept of functioning in the first postpartum year. Women were asked to discuss the responsibilities associated with new motherhood as well as the circumstances surrounding high and low functioning periods. RESULTS: The qualitative data produced by the focus groups were coded by emotive tone and content and translated into item construction for the BIMF, a 20-item self-report measure of functioning intended for use in the year after childbirth. Before implementation into the screening study, the BIMF was critiqued by a panel of experts and cross-checked with the literature to ensure that no major contextual domains were absent. Psychometric testing revealed adequate internal reliability and construct validity, and the BIMF has been implemented successfully in clinical settings. CONCLUSIONS: The high level of patient engagement and psychometric properties associated with the BIMF are indicative of its potential to become a valuable tool for assessing maternal wellness.

Tailoring interventions: understanding medical practice culture.

This article describes the results of a study that used intensive direct observations of eight medical practices to assess the factors affecting the barriers and facilitators to adult immunization for influenza and pneumonia. The study aimed to describe the culture of these practices by identifying key features that facilitate or deter the immunization process. The article presents profiles of six of the eight practices describing their cultural and organizational frameworks. Six features that are critical to an understanding of the cultures of these practices, particularly as they relate to receptivity to influenza immunization for diverse practices and patient populations, are highlighted. These include policies and procedures, funding source, physician philosophy, patient receptivity to provider recommendation, and physical environment and social environment. The article also discusses strategies for applying knowledge about the culture of each practice to introduce appropriate and feasible interventions aimed at increasing immunization rates.