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BACKGROUND: Type 2 diabetes mellitus (T2DM) results in heavy economic and disease burdens in Louisiana. The Centers for Medicare and Medicaid Services has reimbursed non-face-to-face chronic care management (NFFCCM) for patients with two or more chronic conditions since 2015. OBJECTIVE: To assess the impacts of NFFCCM on healthcare utilization and health outcomes. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included Medicare fee-for-service beneficiaries with T2DM and at least one additional chronic disease between 2014 and 2018. EXPOSURES: At least one record of NFFCCM Current Procedural Terminology codes. MAIN MEASURES: The health outcomes in the study included major adverse cardiovascular events (MACE), all-cause mortality, and heart failure. The monthly service utilization and continuity of care index for primary care were also included. The propensity score method was used to balance the baseline differences between the two groups. Weighted multivariate regression models were developed using propensity score weights to assess the impacts of NFFCCM on outcomes. KEY RESULTS: During the 5 years of study period, 8415 patients among the 118,643 Medicare beneficiaries received at least one NFFCCM. Patients receiving any NFFCCM had reduced healthcare utilization compared with patients not receiving NFFCCM, including 0.012 (95% CI - 0.014 to - 0.011; p < 0.001) fewer monthly hospital admissions, 0.017 (95% CI - 0.019 to - 0.016; p < 0.001) fewer monthly ED visits, and 0.399 (95% CI 0.375 to 0.423; p < 0.001) more monthly outpatient encounters. Patients receiving NFFCCM services had lower MACE event rates of 7.4% (95% CI 7.1 to 7.8%; p < 0.001), all-cause mortality rate of 7.8% (95% CI 7.4 to 8.1%; p < 0.001), and heart failure rate of 0.3% (95% CI 0.2 to 0.5%; p < 0.001), respectively. CONCLUSIONS AND RELEVANCE: These findings suggest that reimbursement for NFFCCM was associated with the shifting high-cost utilization to lower-cost primary health care settings among patients with diabetes in Louisiana.
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Diabetes Mellitus Tipo 2 , Medicare , Aceitação pelo Paciente de Cuidados de Saúde , Humanos , Estados Unidos/epidemiologia , Feminino , Masculino , Idoso , Medicare/estatística & dados numéricos , Estudos Retrospectivos , Diabetes Mellitus Tipo 2/terapia , Diabetes Mellitus Tipo 2/economia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso de 80 Anos ou mais , Planos de Pagamento por Serviço Prestado , Doença CrônicaRESUMO
BACKGROUND: Most wars are fought in poor countries and result in significant proportions of disabilities and mortalities. The consequences of wars and political instability on health workers and access to healthcare remain under-studied. This study aimed to explore the lived experience of healthcare providers amidst war and siege, in a teaching hospital in northern Ethiopia. METHODS: The study was conducted between February 2022 to March 2022. A qualitative phenomenological study was conducted between February to March 2022 with 20 healthcare providers working in Ayder Comprehensive and Specialized Hospital (ACSH), Tigray, Ethiopia, during the Tigray War. The study employed in-depth interviews. RESULTS: The main themes identified included the consequences of the siege on health service delivery at ACSH, personal survival threats posed by the siege, immediate health consequences of the siege among care providers, and consequences of the siege on the motivation and energy of health professionals. CONCLUSIONS: Health workers are exposed to a range of direct and indirect impacts of war, emphasizing the need to amend the conditions in which they live and work.
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Instalações de Saúde , Pessoal de Saúde , Humanos , Etiópia , Hospitais Especializados , Hospitais de EnsinoRESUMO
INTRODUCTION: A life course perspective in maternal, child, and family health allows for integrated exploration of outcomes, incorporating multifactorial determinants of health to interrogate sources of inequity and identify opportunities for intervention. This article explores the historical development, integration, and implications of the contemporary life course perspective in the field of maternal and child health (MCH), and particularly the people and events which institutionalized the framework as central to national and local MCH practice and research over the last decades. METHODS: Drawing on an oral history approach, key leaders of the life course movement in MCH were interviewed. Lived experiences and personal recollections of six interviewees were recorded and synthesized using a narrative descriptive approach to portray the social ecology of the movement's origins. RESULTS: We documented systematic efforts made in the first two decades of the 21st century to consciously promote life course through convening a National MCH Life Course Invitational Meeting, incorporating life course as a foundational framework for strategic planning at the Maternal Child Health Bureau, and development of tools and resources by MCH professional organizations. DISCUSSION: The integration of life course theory into the MCH field signified a major shift towards addressing protective and social factors, which aligns with the field's historical emphasis on social justice and rights-based approaches, and parallels the broader public health movement towards social determinants of health and the need to address structural racism. The ongoing relevance of the life course approach in promoting reproductive justice and addressing inequities in health underscores the historical importance of its adoption and use in the current mainstream of MCH research, policy, and practice.
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BACKGROUND: The Deep South of the United States, and Louisiana in particular, bears a greater burden of obesity, diabetes, and heart disease compared with other regions in the United States. Throughout the COVID-19 pandemic, there has been a substantial increase in telehealth visits for diabetes management to protect the safety of patients. Although there have been significant advancements in telehealth and chronic disease management, little is known about patient and provider perspectives on the challenges and benefits of telehealth visits among people living with diabetes and providers who care for patients with diabetes in Louisiana. OBJECTIVE: This study aimed to explore barriers, facilitators, challenges, and benefits to telehealth for patients with diabetes and health care providers as they transitioned from in-person to remote care during the early COVID-19 pandemic to understand potential optimization. METHODS: A total of 24 semistructured qualitative interviews were conducted with 18 patients living with diabetes and 6 clinicians who served patients with diabetes to explore their experiences and perceptions of telehealth services for diabetes care. Approximately half of the participants identified as Black or African American, half as White, and 75% as female. Interviews were recorded, transcribed, and coded by experienced qualitative researchers using inductive and deductive techniques. A narrative, descriptive approach to the patient and clinician journey framed the study, including the development of internal journey maps, and reflexive thematic analysis was applied to the transcripts, with special attention to barriers and facilitators. RESULTS: In total, 5 themes illustrated barriers and facilitators for participants: convenience, safety, and comfort are the benefits of telehealth for patients and clinicians; yet telehealth and in-person visits are valued differently; the convenience of telehealth may have a downside; technology acts as a double-edged sword; and managing expectations and efficiency of the visit experience was an important factor. Individual experiences varied in relation to several factors, including comfort level and access to technology, health system protocols for providing telemedicine, and level of diabetes control among patients. CONCLUSIONS: Recommendations for optimization include providing support to help guide and inform patients about what to expect and how to prepare for telehealth visits as well as allowing clinicians to schedule telehealth and in-person visits during discrete blocks of time to improve efficiency. Further research should address how hybrid models of telehealth and in-person care may differentially impact health outcomes for patients with diabetes, particularly for people with multiple chronic conditions in settings where access to technology and connectivity is not optimal.
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Diabetes Mellitus , Telemedicina , Feminino , Humanos , Negro ou Afro-Americano , COVID-19 , Diabetes Mellitus/terapia , Pandemias , Pesquisa Qualitativa , Estados Unidos , Brancos , MasculinoRESUMO
AIMS: We evaluated the impact of reimbursement for non-face-to-face chronic care management (NFFCCM) on comprehensive metabolic risk factors among multimorbid Medicare beneficiaries with type 2 diabetes in Louisiana. MATERIALS AND METHODS: We implemented a propensity score method to obtain comparable treatment (n=1501 with NFFCCM) and control (n=17,524 without NFFCCM) groups. Patients with type 2 diabetes were extracted from the electronic health records stored in REACHnet. The study period was from 2013 to February 2020. The comprehensive metabolic risk factors included the primary outcome of glycated hemoglobin (HbA1c) (as the primary outcome) and the secondary outcomes of body mass index (BMI), systolic blood pressure (BP), and low-density lipoprotein cholesterol. RESULTS: Receiving any NFFCCM was associated with improvement in all outcomes measures: a reduction in HbA1c of 0.063% (95% CI: 0.031%-0.094%; P <0.001), a reduction in BMI of 0.155 kg/m 2 (95% CI: 0.029-0.282 kg/m 2 ; P =0.016), a reduction in systolic BP of 0.816 mm Hg (95% CI: 0.469-1.163 mm Hg; P <0.001), and a reduction in low-density lipoprotein cholesterol of 1.779 mg/dL (95% CI: 0.988 2.570 mg/dL; P <0.001). Compared with the control group, the treatment group had 1.6% more patients with HbA1c <7% (95% CI: 0.3%-2.9%; P =0.013). CONCLUSIONS: Patients with diabetes in Louisiana receiving NFFCCM experienced better control of HbA1c, BMI, BP, and low-density lipoprotein outcomes.
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Diabetes Mellitus Tipo 2 , Reembolso de Seguro de Saúde , Idoso , Humanos , Biomarcadores , Colesterol , Diabetes Mellitus Tipo 2/terapia , Hemoglobinas Glicadas , Lipoproteínas LDL , Medicare , Estados Unidos , Multimorbidade , LouisianaRESUMO
OBJECTIVES: We evaluated the impact of reimbursement for non-face-to-face chronic care management (NFFCCM) on healthcare utilization among Medicare beneficiaries with type 2 diabetes in Louisiana. METHODS: We implemented group-based trajectory balancing and propensity score matching to obtain comparable treatment (with NFFCCM) and control (without NFFCCM) groups at baseline. Patients with diabetes with Medicare as their primary payer at baseline were extracted using electronic health records of 3 health systems from Research Action for Health Network, a Clinical Research Network. The study period is from 2013 to early 2020. Our outcomes include general healthcare utilization (outpatient, emergency department, and inpatient encounters) and health utilization related to diabetic complications. We tested each of these outcomes according to multiple treatment definitions and different subgroups. RESULTS: Receiving any NFFCCM was associated with an increase in outpatient visits of 657 (95% confidence interval [CI] 626-687; P < .001) per 1000 patients per month, a decrease in inpatient admissions of 5 (95% CI 2-7; P < .001) per 1000 patients per month, and a decrease in emergency department visits of 4 (95% CI 1-7; P = .005) per 1000 patients per month after 24-month follow-up from initial NFFCCM encounter. Both complex and noncomplex NFFCCM significantly increased visits to outpatient services and inpatient admissions per month. Receiving NFFCCM has a dose-response association with increasing outpatient visits per month. CONCLUSIONS: Patients with diabetes in Louisiana who received NFFCCM had more low-cost primary healthcare and less high-cost healthcare utilization in general. The cost savings of NFFCCM in diabetes management could be further explored in the future.
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Diabetes Mellitus Tipo 2 , Idoso , Humanos , Estados Unidos , Diabetes Mellitus Tipo 2/tratamento farmacológico , Medicare , Louisiana , Atenção à Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Estudos RetrospectivosRESUMO
ABSTRACT: The present study aimed to examine the interrelationships of prenatal psychopathology (specifically symptom cluster), dispositional mindfulness, and rumination using network analysis. Network analysis estimates the links between symptoms and can evaluate the presence and strength of the links. A total of 1122 pregnant women were recruited from a tertiary hospital in China. Psychopathology symptoms (including anxiety, depression, stress, fatigue, sleep, fear of childbirth [FOC], and memory problems) were assessed and used along with mindfulness and rumination to construct networks of association using R. Results illustrated five communities within the network. Anxiety resulted in the highest strength of centrality followed by two symptoms: FOC and retrospective memory. Paths showed that mindfulness was directly connected to depression, prospective memory, retrospective memory, and lack of positive anticipation in FOC, whereas mindfulness was connected indirectly through rumination to anxiety, fatigue, stress, and sleep problems. The findings reinforce that anxiety is a key symptom of prenatal psychopathology and requires priority consideration. The direct associations between mindfulness and prenatal psychopathology symptoms provide potential targets for future mindfulness-based interventions, and mindfulness reducing rumination thus in turn decrease anxiety, suggesting potential mediating mechanism of mindfulness.
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Atenção Plena , Ansiedade , Transtornos de Ansiedade , Depressão , Fadiga , Feminino , Humanos , Gravidez , Estudos Retrospectivos , SíndromeRESUMO
AIM: To investigate the association between visit-to-visit HbA1c variability and the risk of cardiovascular disease in patients with type 2 diabetes. MATERIALS AND METHODS: We performed a retrospective cohort study of 29 260 patients with at least four HbA1c measurements obtained within 2 years of their first diagnosis of type 2 diabetes. Different HbA1c variability markers were calculated, including the standard deviation (SD), coefficient of variation (CV) and adjusted SD. Cox proportional hazards regression models were used to estimate the association of these HbA1c variability markers with incident cardiovascular disease. RESULTS: During a mean follow-up of 4.18 years, a total of 3746 incident cardiovascular disease cases were diagnosed. Multivariate-adjusted hazard ratios for cardiovascular disease across the first, second, third and fourth quartiles of HbA1c SD values were 1.00, 1.30 (95% confidence interval [CI] 1.18-1.42), 1.40 (95% CI 1.26-1.55) and 1.59 (95% CI 1.41-1.77) (P for trend <.001), respectively. When we utilized HbA1c CV and adjusted HbA1c SD values as exposures, similar positive associations were observed. HbA1c variability was also associated with the risk of first and recurrent severe hypoglycaemic events. A mediating effect of severe hypoglycaemia was observed between HbA1c variability and incident cardiovascular disease. CONCLUSIONS: Large visit-to-visit HbA1c variability is associated with an increased risk of cardiovascular disease in patients with type 2 diabetes. Severe hypoglycaemia may mediate the association between HbA1c variability and incident cardiovascular disease.
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Doenças Cardiovasculares , Diabetes Mellitus Tipo 2 , Glicemia , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/epidemiologia , Hemoglobinas Glicadas/análise , Humanos , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Despite potential for benefit, mindfulness remains an emergent area in perinatal mental health care, and evidence of smartphone-based mindfulness training for perinatal depression is especially limited. OBJECTIVE: The objective of this study was to evaluate the effectiveness of a smartphone-based mindfulness training intervention during pregnancy on perinatal depression and other mental health problems with a randomized controlled design. METHODS: Pregnant adult women who were potentially at risk of perinatal depression were recruited from an obstetrics clinic and randomized to a self-guided 8-week smartphone-based mindfulness training during pregnancy group or attention control group. Mental health indicators were surveyed over five time points through the postpartum period by online self-assessment. The assessor who collected the follow-up data was blind to the assignment. The primary outcome was depression as measured by symptoms, and secondary outcomes were anxiety, stress, affect, sleep, fatigue, memory, and fear. RESULTS: A total of 168 participants were randomly allocated to the mindfulness training (n=84) or attention control (n=84) group. The overall dropout rate was 34.5%, and 52.4% of the participants completed the intervention. Mindfulness training participants reported significant improvement of depression (group × time interaction χ24=16.2, P=.003) and secondary outcomes (χ24=13.1, P=.01 for anxiety; χ24=8.4, P=.04 for positive affect) compared to attention control group participants. Medium between-group effect sizes were found on depression and positive affect at postintervention, and on anxiety in late pregnancy (Cohen d=0.47, -0.49, and 0.46, respectively). Mindfulness training participants reported a decreased risk of positive depressive symptom (Edinburgh Postnatal Depression Scale [EPDS] score>9) compared to attention control participants postintervention (odds ratio [OR] 0.391, 95% CI 0.164-0.930) and significantly higher depression symptom remission with different EPDS reduction scores from preintervention to postintervention (OR 3.471-27.986). Parity did not show a significant moderating effect; however, for nulliparous women, mindfulness training participants had significantly improved depression symptoms compared to nulliparous attention control group participants (group × time interaction χ24=18.1, P=.001). CONCLUSIONS: Smartphone-based mindfulness training is an effective intervention in improving maternal perinatal depression for those who are potentially at risk of perinatal depression in early pregnancy. Nulliparous women are a promising subgroup who may benefit more from mindfulness training. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR1900028521; http://www.chictr.org.cn/showproj.aspx?proj=33474.
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Depressão/psicologia , Saúde Mental/normas , Atenção Plena/métodos , Assistência Perinatal/métodos , Smartphone/normas , Telemedicina/métodos , Adulto , Feminino , Humanos , Gravidez , Inquéritos e QuestionáriosRESUMO
AIM: To compare the cardiovascular risks between users and non-users of sodium-glucose co-transporter-2 (SGLT2) inhibitors based on electronic medical record data from a large integrated healthcare system in South Louisiana. MATERIALS AND METHODS: Demographic, anthropometric, laboratory and medication prescription information for patients with type 2 diabetes who were new users of SGLT2 inhibitors, either as initial treatments or as add-on treatments, were obtained from electronic health records. Mediation analysis was performed to evaluate the association of use of SGLT2 inhibitors and changes of metabolic risk factors with the risk of incident ischaemic heart disease. RESULTS: A total of 5338 new users of SGLT2 inhibitors were matched with 13 821 non-users. During a mean follow-up of 3.26 years, 2302 incident cases of ischaemic heart disease were defined. After adjusting for multiple confounding factors, patients using SGLT2 inhibitors had a lower risk of incident ischaemic heart disease compared to patients not using SGLT2 inhibitors (hazard ratio [HR] 0.63, 95% confidence interval [CI] 0.54-0.73). Patients using SGLT2 inhibitors also had a lower risk of incident ischaemic heart disease within 6 months (HR 0.36, 95% CI 0.25-0.44), 12 months (HR 0.40, 95% CI 0.32-0.49), 24 months (HR 0.53, 95% CI 0.43-0.60) and 36 months (HR 0.65, 95% CI 0.54-0.73), respectively. Reductions in systolic blood pressure partly mediated lowering risk of ischaemic heart disease among patients using SGLT2 inhibitors. CONCLUSIONS: The real-world data in the present study show the contribution of SGLT2 inhibitors to reducing risk of ischaemic heart disease, and their benefits beyond glucose-lowering.
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Diabetes Mellitus Tipo 2 , Inibidores da Dipeptidil Peptidase IV , Isquemia Miocárdica , Inibidores do Transportador 2 de Sódio-Glicose , Simportadores , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/epidemiologia , Glucose , Humanos , Louisiana , Isquemia Miocárdica/epidemiologia , Isquemia Miocárdica/prevenção & controle , Sódio , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêuticoRESUMO
Background and Purpose- Few studies have assessed the association of HDL (high-density lipoprotein) cholesterol with stroke risk among patients with type 2 diabetes mellitus. We aimed to investigate the association of HDL cholesterol with total and type-specific stroke risk in patients with type 2 diabetes mellitus. Methods- We performed a retrospective cohort study of 27 113 blacks and 40 431 whites with type 2 diabetes mellitus. Cox proportional hazards regression models were used to estimate the association of different levels of HDL cholesterol with stroke risk. Results- During a mean follow-up period of 3.0 years, 8496 patients developed stroke (8048 ischemic and 448 hemorrhagic). Multivariable-adjusted hazard ratios across levels of HDL at baseline (<30 [reference group], 30-39.9, 40-49.9, 50-59.9, 60-69.9, 70-79.9, and ≥80 mg/dL) were 1.00, 0.86, 0.77, 0.71, 0.71, 0.77, and 0.69 ( Ptrend <0.001) for total stroke, 1.00, 0.89, 0.82, 0.75, 0.78, 0.76, and 0.75 ( Ptrend <0.001) for ischemic stroke, and 1.00, 0.89, 0.69, 0.66, 0.47, and 0.94 ( Ptrend =0.021) for hemorrhagic stroke, respectively. When we used an updated mean value of HDL cholesterol, the inverse association of HDL cholesterol with stroke risk did not change. This inverse association was consistent among patients of different ages, races, sexes, body mass index, hemoglobin A1c levels, never and past or current smokers, and patients with and without using glucose-lowering, cholesterol-lowering, or antihypertensive agents. Conclusions- The present study found consistent inverse associations between HDL cholesterol and the risk of total, ischemic and hemorrhagic stroke among patients with type 2 diabetes mellitus.
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Isquemia Encefálica/etiologia , Hemorragia Cerebral/etiologia , HDL-Colesterol/sangue , Diabetes Mellitus Tipo 2/complicações , Anti-Hipertensivos/uso terapêutico , Índice de Massa Corporal , Isquemia Encefálica/sangue , Isquemia Encefálica/epidemiologia , Hemorragia Cerebral/sangue , Hemorragia Cerebral/epidemiologia , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/tratamento farmacológico , Feminino , Seguimentos , Hemoglobinas Glicadas/análise , Humanos , Hipoglicemiantes/uso terapêutico , Louisiana/epidemiologia , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Risco , Fumar/epidemiologia , Hemorragia Subaracnóidea/sangue , Hemorragia Subaracnóidea/epidemiologia , Hemorragia Subaracnóidea/etiologiaRESUMO
Balms and oils containing terpenic compounds, such as camphor, menthol and eucalyptus, are potentially toxic, and numerous reports of adverse events stemming from their use in infants and young children have been published. During qualitative research on newborn practices in rural Cambodia, these products were found to be commonly applied to the skin of newborns and infants and available in most households. Parents and caregivers of infants in Cambodia and other settings where use of camphor- and menthol-containing products are common should be educated on the risks of these to prevent child morbidity and potential mortality.
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Cânfora/toxicidade , Terapias Complementares/estatística & dados numéricos , Fármacos Dermatológicos/toxicidade , Conhecimentos, Atitudes e Prática em Saúde , Cuidado do Lactente/métodos , Comportamento Materno , Óleos Voláteis/toxicidade , Camboja , Terapias Complementares/efeitos adversos , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pesquisa QualitativaRESUMO
BACKGROUND: Nigeria's Maternal, newborn, and child health and nutrition (MNCH+N) outcomes rank among the world's poorest. Engaging traditional and religious leaders shows promise in promoting related behaviors. The Breakthrough ACTION/Nigeria project worked with leaders in northern Nigeria to implement the Advocacy Core Group (ACG) model, a social and behavior change (SBC) approach aimed at influencing community norms and promoting uptake of MNCH+N behaviors. Qualitative assessment of the model contributes to evidence on SBC approaches for enhancing integrated health behaviors. METHODOLOGY: This qualitative study was conducted in Nigeria's Bauchi and Sokoto states in May 2021. It involved 51 in-depth interviews and 24 focus group discussions. The study was grounded in the social norms exploration (SNE) technique to examine normative factors influencing behavior change within the ACG model context. Data analysis used a reflexive thematic analysis approach. Ethical approvals were received from all involved institutions and informed consent was obtained from participants. RESULTS: The ACG model was vital in the uptake of MNCH+N behaviors. The influence of ACG members varied geographically with greater impact observed in Sokoto State. Normative barriers to improving MNCH+N outcomes included perceived religious conflicts with family planning, preference for traditional care in pregnancy, misinformation on exclusive breastfeeding (EBF), and gender-based violence resulting from women's decision-making. The study demonstrated positive progress in norm shifting, but EBF and GBV norms showed slower changes. Broader challenges within the health system, such as inadequate services, negative attitudes of healthcare providers, and workforce shortages, hindered access to care. CONCLUSION: The ACG model increased awareness of health issues and contributed to potential normative shifts. However, slower changes were observed for EBF and GBV norms and broad health system challenges were reported. The model appears to be a promising strategy to further drive SBC for better health outcomes, especially where it is combined with supply-side interventions.
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Normas Sociais , Humanos , Nigéria , Feminino , Adulto , Masculino , Recém-Nascido , Gravidez , Pesquisa Qualitativa , Liderança , Grupos Focais , Saúde da Criança , Comportamentos Relacionados com a Saúde , Pessoa de Meia-Idade , Saúde Materna , Criança , Adulto JovemRESUMO
[This corrects the article DOI: 10.2196/43101.].
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[This corrects the article DOI: 10.1371/journal.pone.0231524.].
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OBJECTIVE: This paper examines the acceptance of the Advocacy Core Group (ACG) programme, a social and behaviour change intervention addressing maternal, newborn, child health and nutrition (MNCH+N) in Bauchi and Sokoto states, with an additional focus on the perceived endorsement of health behaviours by social networks as a potential factor influencing acceptance. DESIGN: This study used the qualitative social network analysis approach and used in-depth interviews to collect data from 36 participants across Bauchi and Sokoto states. SETTING: This study was conducted in selected communities across Bauchi and Sokoto states. PARTICIPANTS: A purposive sample of 36 participants comprised of men and women aged 15-49 years who have been exposed to the ACG programme. RESULTS: Programme beneficiaries actively engaged in various ACG-related activities, including health messaging delivered through religious houses, social gatherings, home visits, community meetings and the media. As a result, they reported a perceived change in behaviour regarding exclusive breast feeding, antenatal care visits, family planning and malaria prevention. Our findings indicated consistent discussions on health behaviours between programme beneficiaries and their network partners (NPs), with a perceived endorsement of these behaviours by the NPs. However, a potential negative factor emerged, whereby NPs exhibited perceived disapproval of key behaviours, which poses a threat to behaviour adoption and, consequently, the success of the ACG model. CONCLUSIONS: While findings suggest the successful implementation and acceptance of the model, it is important to address possible barriers and to further explore the socially determined acceptance of MNCH+N behaviours by NPs. Interventions such as the ACG model should mobilise the networks of programme participants, particularly those with decision-making power, to improve the uptake of health behaviours.
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Saúde da Criança , Cuidado Pré-Natal , Masculino , Criança , Recém-Nascido , Feminino , Humanos , Gravidez , Nigéria , Pesquisa Qualitativa , Aceitação pelo Paciente de Cuidados de SaúdeRESUMO
OBJECTIVES: In 2015, CMS implemented reimbursement for non-face-to-face chronic care management (NFFCCM) for beneficiaries with multiple chronic conditions, including diabetes. This analysis estimated the association between NFFCCM and utilization of inpatient, outpatient, and emergency services. STUDY DESIGN: We implemented a doubly robust estimator using propensity score matching in a regression context to compare eligible patients who used NFFCCM (n = 282) with eligible patients who did not use NFFCCM (n = 26,759). METHODS: We tested 4 definitions of treatment: having any NFFCCM encounters and having 1 NFFCCM encounter per month, per 2 months, and per 3 months. Two-tailed statistical inference testing was conducted at the 5% level. We examined the utilization differences among patients with diabetes 65 years and older using merged electronic health records for 4 health systems in Louisiana from the Research Action for Health Network database in 2013 through 2018. RESULTS: We found NFFCCM was associated with increased utilization of care in the outpatient setting by 0.056 visits per month (95% CI, 0.027-0.086) and with lower utilization in the inpatient setting (-0.024 visits per month; 95% CI, -0.038 to -0.010) and in the emergency department setting (-0.017 visits per month; 95% CI, -0.031 to -0.003). Alternative specifications of treatment showed similar associations. CONCLUSIONS: CMS implementation of reimbursement codes for NFFCCM, and subsequent utilization of that reimbursement by health systems, was associated with a shift in patient utilization from high-cost settings (inpatient and emergency department) to a lower-cost setting (outpatient office).
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Diabetes Mellitus , Pacientes Internados , Humanos , Pacientes Ambulatoriais , Diabetes Mellitus/terapia , Bases de Dados Factuais , Registros Eletrônicos de SaúdeRESUMO
BACKGROUND: Health inequalities are rooted in historically unjust differences in economic opportunities, environment, access to health care services, and other social determinants. Owing to these health inequalities, the COVID-19 pandemic has disproportionately affected underserved populations, notably people of color, incarcerated and formerly incarcerated individuals, and those unable to physically distance themselves from others. However, people most strongly impacted by health disparities, and the pandemic, are not frequently engaged in research, either as researchers or as participants, resulting in slow progress toward improving health equity. Establishing ways to foster the engagement of historically excluded people is crucial to improving health equity through patient-centered health research. OBJECTIVE: This study aimed to assess the use of equity-centered design thinking (EDT) for engaging community members in research prioritization related to COVID-19. The co-design methods and subsequent production of a toolkit that can be used for engagement were assessed through process evaluation and qualitative methods. METHODS: Process evaluation and qualitative inquiry, using reflexive thematic analysis, were undertaken to examine the use of EDT. Patient community members and stakeholders remotely partnered with design and health researchers in a year-long digital process to cocreate capacity-building tools for setting agenda for research regarding the impact of COVID-19 on health outcomes. Through a series of 3 workshops, 5 community partners engaged in EDT activities to identify critical challenges for the health and well-being of their communities. The subsequent tools were tested with 10 health researchers who provided critical input over the course of 2 workshops. Interviews with co-designers, project materials, and feedback sessions were used in the process evaluation and finalization of an equity-centered toolkit for community engagement in research. Data from the co-design process, meetings, workshops, and interviews were analyzed using reflexive thematic analysis to identify salient themes. RESULTS: Process evaluation illustrated how the EDT co-design process offered an approach to engage patient partners and community stakeholders in health-related research around COVID-19. The participants expressed satisfaction with design thinking approaches, including creative activities and iterative co-design, as a means of working together. Thematic analysis identified 3 key themes: the value of authentic partnerships, building trust and empathy through design, and fostering candid dialogue around health and social issues impacting historically underrepresented and underinvested communities. CONCLUSIONS: The project addressed the need to test EDT strategies for fostering inclusive community engagement in health research agenda setting and provided an alternative to traditional top-down models. Despite the increasing use of human-centered design in health, few projects explicitly include equity in design thinking approaches. The use of methods and tools to intentionally engage underrepresented stakeholders in the process of research agenda setting and equitably sharing power between researchers and community members may improve health research, ultimately improving health equity.
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Background: Early childhood is the key life course period for development of social-emotional skills, providing the foundation for school readiness and resilience in later life. Age-appropriate yoga and mindfulness programs may contribute to the development of critical skills in children. Young children from minoritized communities that face structural racism and health disparities may benefit from programs that support social-emotional development and contribute to future academic success. Systematic reviews of yoga interventions for young children have indicated the potential for effectiveness in supporting social-emotional development, executive function, and physical activity. However, studies of yoga and mindfulness with non-White children are sparse and, overall, the evidence base to date for such programs remains limited by non-controlled studies and the variable quality of studies evaluating programs in early childhood settings. Methods: The analysis of data from a non-randomized, controlled intervention aimed to assess the effect of exposure to a yoga and mindfulness program for early childhood development of social-emotional skills in a majority Black/African American urban preschool setting in southeastern US. Children in the intervention received group yoga and mindfulness led by a certified children's yoga teacher who also had training and experience as a school teacher. Intervention participants engaged in activities for 20 minutes once per week for 32 weeks, while the control group had no yoga. The final sample included 579 in the historical control group and 122 in the intervention group. Results: Results indicated that children who participated in the yoga and mindfulness program had higher total protective factor (TPF) subscores on the Devereux Early Childhood Assessment over time than children who did not receive yoga and mindfulness programming, and that the difference was statistically significant (P<0.05). Participation in the intervention group significantly predicted increases in initiative score, self-control score, and TPF score, as well as a decrease in the behavioral concerns. Discussion: School based yoga and mindfulness programming can support social-emotional skills and resilience in young children. Additional studies with larger sample sizes and randomization are needed on use of yoga and mindfulness in young children for social-emotional development, particularly for Black/African American children and others from minoritized communities.
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Utilization of high-quality clinical practice guidelines has the potential to positively impact health outcomes. This study aimed to assess the quality and content concordance of national and international recommendations on hypertensive disorders of pregnancy (HDPs). Searches were conducted of the MEDLINE database and reference lists generated from national and international agencies. Covidence software was used for the management of the systematic review process, the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was used to assess guidelines for quality, and three reviewers independently screened records. The research team identified and screened a total of 399 records of which 10 were deemed high quality. Guidelines were assessed and compared regarding the treatment, prevention, and categorization of disorders. The quality of guidelines varied across different domains, with significant variation in domain scores even within individual guidelines. Not all recommendations showed a high level of methodologic rigor, and the highest-rated guidelines were from the American Heart Association, the World Health Organization, and South Africa national guidelines. Classification of hypertension differed among the guidelines, particularly in defining chronic hypertension, severe hypertension, and preeclampsia. Prevention modalities varied across guidelines, with recommendations for aspirin, calcium supplementation, and against the use of certain approaches. Treatment modalities highlighted the importance of delivery as the definitive way to terminate hypertensive disorders of pregnancy, with other management strategies provided for symptom control. The variability in guidelines and consensus statements across different contexts may reflect regional differences in healthcare practices, available resources, and research evidence. There is potential to harmonize guidelines for HDP globally while considering the unique needs of individual countries. Where guidelines may be synthesized and condensed into an accessible format, doing so could improve their use in clinical decision-making.