A Secret Shopper Study of Language Accessibility of Community-Based Behavioral Health Services for Children in Families Who Speak Spanish and English.

OBJECTIVE: The objective of this study was to compare outpatient behavioral health scheduling for children in Spanish-speaking families in Pennsylvania with that for children in families who speak English. STUDY DESIGN: We made paired English and Spanish telephone calls to outpatient behavioral health facilities using a standardized script, describing a simulated, stable, Medicaid-insured child. Facilities were identified using the Pennsylvania Department of Human Services Online Provider Directory for Mental Health and Substance Abuse Services, which had 288 outpatient facilities with nonduplicate telephone numbers. An English-language caller following a script made up to 2 call attempts per facility from December 2019 through February 2020. The 126 facilities that did not answer the phone, accept Medicaid, or see children were removed. A Spanish-language caller then made up to 2 scripted call attempts to the 162 remaining facilities. The primary outcome was whether the facility tried to schedule an appointment for the simulated adolescent. RESULTS: A total of 125 facilities answered both English- and Spanish-language calls. For the English-language caller, 71% of facilities attempted to schedule an appointment and 100% communicated in the caller's preferred language. For the Spanish-language caller, 24% attempted to schedule an appointment (P < .001) and 25% communicated in the caller's preferred language (P < .001). CONCLUSIONS: Among outpatient behavioral health facilities for Medicaid-insured children in Pennsylvania, there were inequities in access to appointments for families who speak Spanish compared with English. This is a modifiable barrier to care. Community-based behavioral health care for children should strengthen language access training, contracting, and oversight.

Associations of financial strain and unmet social needs with women's bladder health.

OBJECTIVE: Financial strain and unmet social needs are associated with greater risk for lower urinary tract symptoms. Little research has examined financial strain and unmet social needs in relation to the more holistic concept of bladder health. This study utilizes baseline data from RISE FOR HEALTH: A U.S. Study of Bladder Health to examine whether financial strain, unmet social needs, and meeting specific federal poverty level threshold levels are associated with lower urinary tract symptoms and poorer perceived bladder health, well-being, and function. STUDY DESIGN: Participants were 18 years or older, born female or currently identified as a woman, and from the civilian, noninstitutionalized population residing in 50 counties in the United States that included or surrounded 9 recruitment centers. Data were collected through mailed or internet-based surveys. To address research questions, the 10-item Lower Urinary Tract Dysfunction Research Network - Symptom Index and selected Prevention of Lower Urinary Tract Symptoms Research Consortium bladder health scores were separately regressed on each financial strain, unmet social need, and federal poverty level variable, using linear regression adjusting for covariates (age, race/ethnicity, education, and vaginal parity) and robust variance estimation for confidence intervals (CI). Participants with no missing data for a given analysis were included (range of n=2564-3170). In separate sensitivity analyses, body mass index, hypertension, and diabetes were added as covariates and missing data were imputed. RESULTS: The mean age of participants was 51.5 years (standard deviation=18.4). Not having enough money to make ends meet, housing insecurity, food insecurity, unreliable transportation, and percent federal poverty levels of 300% or less were consistently associated with more reported lower urinary tract symptoms and poorer perceived bladder health. For example, compared to food secure participants, women who worried that their food would run out at the end of the month had a Lower Urinary Tract Dysfunction Research Network - Symptom Index score that was 3.4 points higher (95% CI: 2.5, 4.3), on average. They also had lower mean scores across different bladder health measures, each assessed using a 100-point scale: global bladder health (-8.2, 95% CI: -10.8, -5.7), frequency (-10.2, 95% CI: -13.8, -6.7), sensation (-11.6, 95% CI: -15.1, -8.2), continence (-13.3, 95% CI: -16.7, -9.9), and emotional impact of bladder health status (-13.2, 95% CI: -16.5, -9.9). Across analyses, associations largely remained significant after additional adjustment for body mass index, hypertension, and diabetes. The pattern of results when imputing missing data was similar to that observed with complete case analysis; all significant associations remained significant with imputation. CONCLUSION: Financial strain and unmet social needs are associated with worse LUTS and poorer bladder health. Longitudinal research is needed to examine whether financial strain and unmet social needs influence the development, maintenance, and worsening of lower urinary tract symptoms; different mechanisms by which financial strain and unmet social needs may impact symptoms; and the degree to which symptoms contribute to financial strain. If supported by etiologic research, prevention research can be implemented to determine whether the amelioration of financial strain and social needs, including enhanced access to preventative care, may promote bladder health across the life course.

Black women's perspectives on bladder health: Social-ecological and life course contexts.

AIMS: This paper explores Black women's perspectives on bladder health using a social-ecological conceptual framework and life course perspective. METHODS: We conducted a directed content analysis of data from the Study of Habits, Attitudes, Realities, and Experiences (SHARE), a focus group study by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. Analysis was conducted on data from five focus groups and a member-checking session where all participants self-identified as Black or African American. RESULTS: Forty-two participants aged 11-14 or 45+ years reported life course experiences with their bladder. The intersection of race and gender was the lens through which participants viewed bladder health. Participants' accounts of their perspectives on bladder health explicitly and implicitly revealed structural racism as an explanatory overarching theme. Participants described (a) historically-rooted and still pervasive practices of discrimination and segregation, engendering inequitable access to quality medical care and public facilities, (b) institutional barriers to toileting autonomy in educational and occupational settings, promoting unhealthy voiding habits, (c) internalized expectations of Black women's stereotyped role as family caregiver, compromising caregiver health, (d) lack of reliable information on bladder health, leading to unhealthy bladder behaviors, and (e) potentially stress-related comorbid chronic conditions and associated medication use, causing or exacerbating bladder problems. CONCLUSIONS: Bladder health promotion interventions should address social-ecological and life course factors shaping Black women's bladder health, including social and structural barriers to accessing equitable health information and medical care.

Trust and virtual communication during the COVID-19 pandemic for adults with asthma from low-income neighborhoods: What have we learned?

BACKGROUND: Low-income and marginalized adults disproportionately bear the burden of poor asthma outcomes. One consequence of the structural racism that preserves these inequities is decreased trust in government and health care institutions. OBJECTIVE: We examined whether such distrust extended to health care providers during the pandemic. METHODS: We enrolled adults living in low-income neighborhoods who had required a hospitalization, an emergency department visit, or a prednisone course for asthma in the prior year. Trust was a dichotomized measure derived from a 5-item questionnaire with a 5-point Likert scale response. The items were translated to the binary variable "strong" versus "weak" trust. Communication was measured using a 13-item questionnaire with a 5-point Likert scale. Logistic regression was used to examine the association between communication and trust, controlling for potential confounders. RESULTS: We enrolled 102 patients, aged 18 to 78 years; 87% were female, 90% were Black, 60% had some post-high school education, and 57% were receiving Medicaid. Of the 102 patients, 58 were enrolled before the March 12, 2020, pandemic start date, and 70 (69%) named doctors as their most trusted source of health information. Strong trust was associated with a negative response to the statement "It is hard to reach a person in my doctor's office by phone." There was no evidence of an association between the overall communication scores and trust. Satisfaction with virtual messaging was weaker among those with less trust. CONCLUSIONS: These patients trust their physicians, value their advice, and need to have accessible means of communication.

Impact of Stigma on Clinician Training for Opioid Use Disorder Care: A Qualitative Study in a Primary Care Learning Collaborative.

PURPOSE: We undertook a study to examine how stigma influences the uptake of training on medication for opioid use disorder (MOUD) in primary care academic programs. METHODS: We conducted a qualitative study of 23 key stakeholders responsible for implementing MOUD training in their academic primary care training programs that were participants in a learning collaborative in 2018. We assessed barriers to and facilitators of successful program implementation and used an integrated approach to develop a codebook and analyze the data. RESULTS: Participants represented the family medicine, internal medicine, and physician assistant fields, and they included trainees. Most participants described clinician and institutional attitudes, misperceptions, and biases that enabled or hindered MOUD training. Perceptions included concerns that patients with OUD are "manipulative" or "drug seeking." Elements of stigma in the origin domain (ie, beliefs by primary care clinicians or the community that OUD is a choice and not a disease), the enacted domain (eg, hospital bylaws banning MOUD and clinicians declining to obtain an X-Waiver to prescribe MOUD), and the intersectional domain (eg, inadequate attention to patient needs) were perceived as major barriers to MOUD training by most respondents. Participants described strategies that improved the uptake of training, including giving attention to clinician concerns, clarifying the biology of OUD, and ameliorating clinician fears of being ill equipped to provide care for patients. CONCLUSIONS: OUD-related stigma was commonly reported in training programs and impeded the uptake of MOUD training. Potential strategies to address stigma in the training context, beyond providing content on effective evidence-based treatments, include addressing the concerns of primary care clinicians and incorporating the chronic care framework into OUD treatment.

A community-engaged approach to the design of a population-based prospective cohort study to promote bladder health.

INTRODUCTION: Community engagement is increasingly recognized as a critical component of research, but few studies provide details on how to successfully incorporate community perspectives in urological research. This manuscript describes the community engagement strategy used by the Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS) to design RISE FOR HEALTH (RISE), a multicenter, population-based, prospective cohort study to promote bladder health. METHODS AND RESULTS: The PLUS Community Engagement Subcommittee, guided by a set of antiracist community engagement principles and practices, organized, implemented, and communicated findings for all RISE community engagement activities. Community engagement was conducted through a diverse network of community partners at PLUS clinical research centers called Rapid Assessment Partners (RAPs). Via online surveys (4), virtual discussion groups (14), and one-on-one interviews (12), RAPs provided input on RISE processes and materials, including in-person visit procedures, specimen collection instructions, survey data collection instruments, recruitment materials, the study website, and the study name. This process resulted in significant changes to these aspects of the study design with reciprocal benefits for the community partners. DISCUSSION: Meaningful community engagement improved the design and implementation of RISE. PLUS will continue to engage community partners to interpret the RISE study results, disseminate RISE findings, and inform other PLUS studies toward the development of interventions to promote bladder health. Future urological studies would also benefit from community participation in determining priority research questions to address.

RISE FOR HEALTH: Rationale and protocol for a prospective cohort study of bladder health in women.

INTRODUCTION: The spectrum of bladder health and the factors that promote bladder health and prevent lower urinary tract symptoms (LUTS) among women are not well understood. This manuscript describes the rationale, aims, study design, sampling strategy, and data collection for the RISE FOR HEALTH (RISE) study, a novel study of bladder health in women conducted by the Prevention of Lower Urinary Tract Symptom (PLUS) Research Consortium. METHODS AND RESULTS: RISE is a population-based, multicenter, prospective longitudinal cohort study of community-dwelling, English- and Spanish-speaking adult women based in the United States. Its goal is to inform the distribution of bladder health and the individual factors (biologic, behavioral, and psychosocial) and multilevel factors (interpersonal, institutional, community, and societal) that promote bladder health and/or prevent LUTS in women across the life course. Key study development activities included the: (1) development of a conceptual framework and philosophy to guide subsequent activities, (2) creation of a study design and sampling strategy, prioritizing diversity, equity, and inclusion, and (3) selection and development of data collection components. Community members and cross-cultural experts shaped and ensured the appropriateness of all study procedures and materials. RISE participants will be selected by simple random sampling of individuals identified by a marketing database who reside in the 50 counties surrounding nine PLUS clinical research centers. Participants will complete self-administered surveys at baseline (mailed paper or electronic) to capture bladder health and LUTS, knowledge about bladder health, and factors hypothesized to promote bladder health and prevent LUTS. A subset of participants will complete an in-person assessment to augment data with objective measures including urogenital microbiome specimens. Initial longitudinal follow-up is planned at 1 year. DISCUSSION: Findings from RISE will begin to build the necessary evidence base to support much-needed, new bladder health promotion and LUTS prevention interventions in women.

Community-Based COVID-19 Vaccine Clinics in Medically Underserved Neighborhoods to Improve Access and Equity, Philadelphia, 2021-2022.

Vaccination remains key to reducing the risk of COVID-19-related severe illness and death. Because of historic medical exclusion and barriers to access, Black communities have had lower rates of COVID-19 vaccination than White communities. We describe the efforts of an academic medical institution to implement community-based COVID-19 vaccine clinics in medically underserved neighborhoods in Philadelphia, Pennsylvania. Over a 13-month period (April 2021-April 2022), the initiative delivered 9038 vaccine doses to community members, a majority of whom (57%) identified as Black. (Am J Public Health. 2022;112(12):1721-1725. https://doi.org/10.2105/AJPH.2022.307030).

Survey of lower urinary tract symptoms in United States women using the new lower urinary tract dysfunction research Network-Symptom Index 29 (LURN-SI-29) and a national research registry.

PURPOSE: An online bladder health survey was administered to national registry volunteers to: (1) determine the feasibility of using ResearchMatch for studying lower urinary tract symptoms (LUTS); (2) pilot the new, comprehensive Lower Urinary Tract Dysfunction Research Network Symptom Index-29 (LURN-SI-29) and determine its ability to detect known associations with LUTS; and (3) explore novel areas of bladder health in community-based women. METHODS: A cross-sectional web-based survey was administered to a random sample of ResearchMatch adult female, transgender and non-binary volunteers. Participant demographics, health characteristics, the LURN-SI-29, and LUTS-related experiences were collected. RESULTS: A total of 1725 ReseachMatch volunteers with a mean age of 44.0 years completed the study and were eligible for the analysis. Participants were primarily white, cisgendered, highly educated, nulliparous, and premenopausal. The median LURN-SI-29 score was 17 (interquartile range: 11-26). More than half the sample reported urinary urgency (71.0%), nocturia (65.7%), and stress incontinence (52.3%) a "few times" or more in the last 7 days. Approximately half reported sensation of incomplete bladder emptying (49.6%) with one-third reporting urgency incontinence (37.6%); notably, 52.6% of respondents reported being at least "somewhat" bothered by LUTS. LURN-SI-29 scores increased with age, body mass index, decrements in self-reported health, medical comorbidity, parity, menopausal status, and urinary symptom bother, providing evidence of convergent validity. LURN-SI-29 scores varied by race and education, with the lowest scores in Asian and highly educated women. CONCLUSION: Overall, the prevalence and spectrum of LUTS in an online research registry of women volunteers were high and comparable to other population-based samples. The new LURN-SI-29 demonstrated its ability to detect expected associations with demographic and health characteristics in a nonclinical population.

Primary language and the electronic health record patient portal: Barriers to use among Spanish-speaking adults with asthma.

OBJECTIVES: To assess electronic health record patient portal use among Spanish-speaking patients with asthma compared to English-speaking patients and identify barriers to use. METHODS: Using data collected for a PCORI-funded randomized controlled trial to increase patient portal use in low-income adults with uncontrolled asthma, we estimated the association between portal use, measured using surveys and actual user login data, and primary language. Open-ended survey responses were grouped into common themes. RESULTS: Among 301 adults with asthma: age 18-87, 90% female, 17% Spanish speakers; 44% had no portal use during the study. Spanish speakers were less likely to have ever heard of the patient portal than English speakers (p=.001) and reported more difficulty navigating the portal (p<.001). Spanish speakers with low health literacy had less portal use (31%) than their English-speaking counterparts (51%) (p=.02). Compared to high-literacy English speakers, the odds of using the portal for low-literacy Spanish speakers were 0.34 (95% CI 0.14, 0.84) (p=.02). Three-quarters of Spanish speakers cited barriers to portal use compared to one-quarter of English speakers, and many suggested creating a Spanish version to improve user-friendliness. CONCLUSIONS: English-only patient portals may not meet the needs of Spanish-speaking patients with uncontrolled asthma. Health systems serving Spanish-speaking communities should implement patient portals in Spanish.

Stability of food insecurity status in paediatric primary care.

OBJECTIVE: The American Academy of Pediatrics recommends screening for food insecurity (FI) at all well-child visits due to well-documented negative effects of experiencing FI in childhood. Before age 3, children have twelve recommended primary care visits at which screening could occur. Little is known regarding the stability of FI status at this frequency of screening. DESIGN: Data derived from electronic health records were used to retrospectively examine the stability of household FI status. Age-stratified (infant v. toddler) analyses accounted for age-based differences in visit frequency. Regression models with time since last screening as the predictor of FI transitions were estimated via generalised estimating equations adjusting for age and race/ethnicity. SETTING: A paediatric primary care practice in Philadelphia. PARTICIPANTS: 3451 distinct patients were identified whose health record documented two or more household FI screens between April 1, 2012 and July 31, 2018 and were aged 0-3 years at first screen. RESULTS: Overall, 9·5 % of patients had a transition in household FI status, with a similar frequency of transitioning from food insecure to secure (5·0 %) and from food secure to insecure (4·5 %). Families of toddlers whose last screen was more than a year ago were more likely to experience a transition to FI compared with those screened 0-6 months prior (OR 1·91 (95 % CI 1·05, 3·47)). CONCLUSIONS: Screening more than annually may not contribute substantially to the identification of transitions to FI.

Acute pain and self-directed discharge among hospitalized patients with opioid-related diagnoses: a cohort study.

BACKGROUND: Patients with substance use disorders are more likely than those without to have a self-directed hospital discharge, putting them at risk for poor health outcomes including progressing illness, readmissions, and death. Inadequate pain management has been identified as a potential motivator of self-directed discharge in this patient population. The objective of this study was to describe the association between acute pain and self-directed discharges among persons with opioid-related conditions; the presence of chronic pain in self-directed discharges was likewise considered. METHODS: We employed a large database of all hospitalizations at acute care hospitals during 2017 in the city of Philadelphia to identify adults with opioid-related conditions and compare the characteristics of admissions ending with routine discharge versus those ending in self-directed discharge. We examined all adult discharges with an ICD-10 diagnoses related to opioid use or poisoning and inspected the diagnostic data to systematically identify acute pain for the listed primary diagnosis and explore patterning in chronic pain diagnoses with respect to discharge outcomes. RESULTS: Sixteen percent of the 7972 admissions involving opioid-related conditions culminated in self-directed discharge, which was more than five times higher than in the general population. Self-directed discharge rates were positively associated with polysubstance use, nicotine dependence, depression, and homelessness. Among the 955 patients with at least one self-directed discharge, 15.4% had up to 16 additional self-directed discharges during the 12-month observation period. Those admitted with an acutely painful diagnosis were almost twice as likely to complete a self-directed discharge, and for patients with multiple admissions, rates of acutely painful diagnoses increased with each admission coinciding with a cascading pattern of worsening infectious morbidity over time. Chronic pain diagnoses were inconsistent for those patients with multiple admissions, appearing, for the same patient, in one admission but not others; those with inconsistent documentation of chronic pain were substantially more likely to self-discharge. CONCLUSIONS: These findings underscore the importance of pain care in disrupting a process of self-directed discharge, intensifying harm, and preventable financial cost and suffering. Each admission represents a potential opportunity to provide harm reduction and treatment interventions addressing both substance use and pain.

Home visits for uncontrolled asthma among low-income adults with patient portal access.

BACKGROUND: Asthma disproportionately affects low-income and minority adults. In an era of electronic records and Internet-based digital devices, it is unknown whether portals for patient-provider communication can improve asthma outcomes. OBJECTIVE: We sought to estimate the effect on asthma outcomes of an intervention using home visits (HVs) by community health workers (CHWs) plus training in patient portals compared with usual care and portal training only. METHODS: Three hundred one predominantly African American and Hispanic/Latino adults with uncontrolled asthma were recruited from primary care and asthma specialty practices serving low-income urban neighborhoods, directed to Internet access, and given portal training. Half were randomized to HVs over 6 months by CHWs to facilitate competency in portal use and promote care coordination. RESULTS: One hundred seventy (56%) patients used the portal independently. Rates of portal activity did not differ between randomized groups. Asthma control and asthma-related quality of life improved in both groups over 1 year. Differences in improvements over time were greater for the HV group for all outcomes but reached conventional levels of statistical significance only for the yearly hospitalization rate (-0.53; 95% CI, -1.08 to -0.024). Poor neighborhoods and living conditions plus limited Internet access were barriers for patients to complete the protocol and for CHWs to make HVs. CONCLUSION: For low-income adults with uncontrolled asthma, portal access and CHWs produced small incremental benefits. HVs with emphasis on self-management education might be necessary to facilitate patient-clinician communication and to improve asthma outcomes.

Using a Community Workgroup Approach to Increase Access to Physical Activity in an Underresourced Urban Community.

Background. Regular physical activity is associated with improved physical and psychosocial well-being. Increasing access to physical activity in underresourced communities requires collaborative, community-engaged methods. One such method is community workgroups. Purpose. The purpose of this article is to describe implementation, strengths, challenges, and results of the workgroup approach as applied to increasing access to physical activity, using our recent study as an illustrative example. Method. A 1-day conference was held in April 2017 for community leaders. The first half of the conference focused on disseminating results of a multifaceted community assessment. The second half entailed community workgroups. Workgroups focused on applying community assessment results to develop strategies for increasing access to physical activity, with plans for ongoing workgroup involvement for strategy refinement and implementation. A professional artist documented the workgroup process and recommendations via graphic recording. Results. Sixty-three community leaders attended the conference and participated in the workgroups. Workgroup participants reported that greater macrosystem collaboration was critical for sustainability of physical activity programming and that, particularly in underresourced urban communities, re-imagining existing spaces (rather than building new spaces) may be a promising strategy for increasing access to physical activity. Discussion. Considered collectively, the community workgroup approach provided unique insight and rich data around increasing access to physical activity. It also facilitated stakeholder engagement with and ownership of community health goals. With careful implementation that includes attention to strengths, challenges, and planning for long-term follow-up, the community workgroup approach can be used to develop health promotion strategies in underresourced communities.

Filling the patient-provider knowledge gap: a patient advocate to address asthma care and self-management barriers.

Introduction: In an ongoing study, a new clinical role adapted from a patient navigator called the patient advocate (PA) met with patients before medical visits, attended appointments and afterwards reviewed provider instructions. This qualitative analysis examines the perspectives of PAs and providers regarding their experiences with patients to understand how a PA can help patients and providers achieve better asthma control. Methods: PAs recorded journal entries about their experiences with patients. Provider focus groups and interviews were conducted by researchers and transcribed. Analysis was based on the Grounded Theory approach for qualitative research, using open and then focused coding. Two researchers independently coded these sources until intercoder agreement was achieved. Results: Upon review of 31 journal entries on PA experiences with 24 patients and transcripts from 2 provider focus groups and 12 provider interviews, 5 themes emerged surrounding asthma care and self-management: medication adherence, follow-up, communication, social determinants of health and time. While patients shared with PAs specific socioeconomic barriers to medication adherence and follow-up, providers often did not know about these problems and cited barriers to communication. Time restrictions on medical visits further limited communication. Conclusions: Perspectives reported here illustrate a gap in knowledge and understanding between patients and providers. The PA's unique relationship with patients and presence inside and outside of medical visits allowed them to learn contextual patient information unknown to providers. PAs and providers cited numerous ways PAs can help to improve patient-provider mutual understanding.

Reconciling opposing perceptions of access to physical activity in a gentrifying urban neighborhood.

OBJECTIVE: We sought to understand perspectives on access to physical activity in a gentrifying neighborhood. DESIGN: This qualitative descriptive study used street intercept interviews and photo documentation. SAMPLE: Participants included members (n = 19) of a gentrifying neighborhood in a northeastern city. RESULTS: Participants held markedly different perceptions of opportunities for physical activity. Some participants, particularly area university students or those who are identified as White, perceived the neighborhood as favorable to physical activity, with high walkability and abundant resources. Other participants, particularly those who identified as Black or African-American, felt it was difficult to be physically active because neighborhood recreation facilities are scarce or unaffordable and parks are poorly maintained or unsafe. Multiple participants noted strategies to overcome neighborhood barriers to physical activity. Regardless of neighborhood perceptions, family and friends played an important role in influencing physical activity. CONCLUSIONS: Nurses must consider how disparities in actual and perceived access to neighborhood resources influence participation in physical activity, particularly in gentrifying neighborhood. Public health nurses are embedded in the neighborhoods that they serve, providing a unique opportunity to understand and address the impact of neighborhood on health.

Public Libraries As Partners for Health.

INTRODUCTION: Public libraries are free and accessible to all and are centers of community engagement and education, making them logical choices as partners for improving population health. Library staff members routinely assist patrons with unmet health and social needs. METHODS: We used a 100-question, self-administered web survey sent to all library directors listed in the Pennsylvania Library Association database (N = 621), to investigate staff interactions with library patrons to address social determinants of health. We conducted statistical comparisons of quantitative responses and a content analysis of open-ended responses. RESULTS: Respondents (N = 262) reported frequently interacting with patrons around health and social concerns - well beyond those related to literacy and education - including help with employment (94%), nutrition (70%), exercise (66%), and social welfare benefits (51%). Acute emergencies were not uncommon in Pennsylvania's public libraries, with nearly 12% of respondents having witnessed a drug overdose at the library in the past year. Most respondents felt that their professional training left them inadequately prepared to assist patrons with health and social issues. Although at least 40% of respondents offered some health programming at their library branch, their offerings did not meet the high level of need reflected in common patron inquiries. CONCLUSION: The challenges library staff members experience in meeting their patrons' information needs suggest opportunities for public libraries to advance population health. Library staff members need additional training and resources and collaboration with public health and health care institutions to respond to community needs through effective, evidence-based public health programming.

Public Library Staff as Community Health Partners: Training Program Design and Evaluation.

Public libraries are free and open to all-and accessed at high rates by vulnerable populations-which positions them to be key public health allies. However, library staff themselves often feel ill-equipped to address the health and social concerns of their patrons. To fill this gap, we developed a case-based training curriculum to help library staff recognize, engage, and refer vulnerable patrons to appropriate resources. Topics addressed in the training, including homelessness, mental health and substance use disorders, immigration, and trauma, were selected based on findings from a prior community needs assessment. Using a modified measure of self-efficacy, participants ( n = 33) were surveyed before and after each session. Several participants ( n = 7) were also interviewed 4 months after the training was completed. Overall, staff reported significant increases in comfort, confidence, and preparedness in assisting vulnerable patrons across all topic areas. Qualitative findings reflected positive perceived impact and value of the trainings. Staff felt training resources should be made more readily accessible. Improving library staff capacity to address the health and social needs of their patrons can further establish public libraries as partners in improving population health.

A health care navigation tool assesses asthma self-management and health literacy.

BACKGROUND: Self-management of moderate-to-severe asthma depends on the patient's ability to (1) navigate (access health care to obtain diagnoses and treatment), (2) use inhaled corticosteroids (ICSs) properly, and (3) understand ICS function. OBJECTIVE: We sought to test whether navigation skills (medication recall, knowledge of copay requirements, and ability to provide information needed for a medical visit about a persistent cough unresponsive to medication) are related to other self-management skills and health literacy. METHODS: A 21-item Navigating Ability (NAV2) questionnaire was developed, validated, and then read to adults with moderate-to-severe asthma. ICS technique was evaluated by using scales derived from instructions in national guidelines; knowledge of ICS function was evaluated by using a validated 10-item questionnaire. Spearman correlation was computed between NAV2 score and these questionnaires and with numeracy (Asthma Numeracy Questionnaire) and print literacy (Short Test of Functional Health Literacy in Adults). RESULTS: Two hundred fifty adults participated: age, 51 ± 13 years; 72% female; 65% African American; 10% Latino; 50% with household income of less than $30,000/y; 47% with no more than a 12th-grade education; and 29% experienced hospitalizations for asthma in the prior year. A higher NAV2 score was associated with correct ICS technique (ρ = 0.24, P = .0002), knowledge of ICSs (ρ = 0.35, P < .001), better print literacy (ρ = 0.44, P < .001), and numeracy (ρ = 0.41, P < .001). CONCLUSIONS: Patients with poor navigational ability are likely to have poor inhaler technique and limited understanding of ICS function, as well as limited numeracy and print literacy. Clinicians should consider these elements of self-management for their effect on asthma care and as a marker of more general health literacy deficits.

How nurse-led practices perceive implementation of the patient-centered medical home.

PURPOSE: The Affordable Care Act (ACA) promotes the Patient-Centered Medical Home (PCMH) model as a way to improve healthcare quality, the patient experience, and has identified nurse-led primary care as a mechanism meeting the increasing demand for quality primary care. The purpose of this study was to investigate the implementation of a PCMH model in nurse-led primary care practices and to identify facilitators and barriers to the implementation of this model. METHODS: Data were collected through in-depth interviews with providers and staff in nurse-led practices. RESULTS: These data suggest two categories of processes that facilitate the integration of PCMH in the nurse-led practice setting: patient-oriented facilitators and organizational facilitators. In addition, a number of barriers were identified to implementing the PCMH model. Overall, these practices creatively engaged in the transformation process by structuring themselves as a complex adaptive system and building upon the core principles of nurse-led care. CONCLUSION: Since the core principles of nurse-led care map onto many of the same principles of the PCMH model, this study discusses the possibility that nurse-led practices may experience fewer barriers when transitioning into PCMHs.