Developing a Social Determinants of Health Needs Assessment for Colorado Kids (SNACK) Tool for a School-Based Asthma Program: Findings from a Pilot Study.

Background: School-based asthma programs effectively address poorly controlled asthma and asthma disparities, especially when coupled with screening for and addressing social determinants of health (SDOH) needs. Existing screening tools are tailored to clinical settings; therefore, we sought to develop a community-based SDOH screening tool. Design/Methods: We used a four-phase iterative design process to develop and pilot a community-based screening tool. We used a modified Delphi process to identify screening tool domains, identified validated items for inclusion, and developed an appropriate tool layout for populations with limited health/general literacy. Community advisory boards reviewed and refined a draft tool. Next, we conducted a qualitative pilot test of acceptability to parents and feasibility for staff in a community health center. Results: Six domains are included in our SDOH screening tool: health care access, transportation, food insecurity, public benefits, housing, and utilities. In the pilot test, 41 screenings were completed, and 36 parents (16.7% Spanish speaking) provided feedback. Most families understood the purpose of the screening; felt that the questions were clear, appropriate, and quick to complete; and liked the pictures. The clinic's care coordinator expressed a preference for the pilot tool compared to their existing screening tool and recommended improvements to encourage honest reporting by patients. Conclusion: This community-based screening tool addresses key SDOH needs that impact asthma and is acceptable to families. The next steps are to implement the tool in school-based asthma programs to support improvements in asthma outcomes and disparities by identifying and addressing families' unmet SDOH needs.

Notes From the Field: Diverse Partner Perspectives Improve the Usability and Equity Focus of Implementation Guides.

Context: School-based asthma programs (SBAPs) have improved health and educational disparities among youth with asthma. Design: To support scaling out effective SBAPs, our school partners identified a need for online implementation guides that are "always available," to meet the needs of school nurses' demanding schedules. School nurses play a key role in the adoption and implementation of SBAPs, so it is important to ensure the implementation guide would be highly usable and acceptable to them. Objective: Accordingly, our research team collaborated with human-centered design experts to identify the "user journeys" of school nurses and co-created our online implementation guide as a public-facing website with input from local and national school nurse partners. Main Results: In this perspectives article, our school nurse implementation partners and human-centered design experts reflect on challenges overcome in this process of developing a tailored implementation guide to school nurses and offer lessons from the field to others seeking to co-create implementation guides with community partners.

Patient Preferences for Discussing and Acting on Health-Related Needs in Primary Care.

BACKGROUND: Addressing social needs, health behaviors, and mental health may help patients more than traditional medical care. However, these root causes of poor health are difficult to address and the role of primary care is unclear. This qualitative study assesses patient's willingness and motivations to discuss and accept assistance for these needs from their primary care team. METHODS: In July and August of 2020, semi-structured virtual interviews were conducted with family medicine patients (n = 6) and residents of low resource neighborhoods (n = 11) in Richmond, Virginia. Interviews were conducted over Zoom. We conducted a qualitative analysis of patient and resident interview transcripts. A rapid qualitative analysis approach and immersion-crystallization processes were used to identify themes and categories. RESULTS: Interviewees reported varying degrees of comfort discussing topics with their health care team. They were less comfortable discussing needs they considered outside the realm of "traditional primary care" including finances, transportation, and housing, but interviewees expressed willingness to discuss these needs under certain conditions. Important factors were a strong patient-clinician relationship to create a trusted and safe space for discussion, adequate time for discussion during visits, communication of practices' ability to provide resources to help patients, and ensuring appropriate high quality referrals. CONCLUSIONS: Primary care provides opportunity for identifying and addressing needs that adversely impact health. Some needs are more sensitive for patients to work with their care team on, though, there was willingness to work on any need when a strong provider relationship and clinic structure for providing support were in place. This study highlights critical care delivery factors which may be used to enhance patient comfort accepting support for their needs and ultimately improve clinical care and chronic disease management.

How Dissemination and Implementation Science Can Contribute to the Advancement of Learning Health Systems.

Many health systems are working to become learning health systems (LHSs), which aim to improve the value of health care by rapidly, continuously generating evidence to apply to practice. However, challenges remain to advance toward the aspirational goal of becoming a fully mature LHS. While some important challenges have been well described (i.e., building system-level supporting infrastructure and the accessibility of inclusive, integrated, and actionable data), other key challenges are underrecognized, including balancing evaluation rapidity with rigor, applying principles of health equity and classic ethics, focusing on external validity and reproducibility (generalizability), and designing for sustainability. Many LHSs focus on continuous learning cycles, but with limited consideration of issues related to the rapidity of these learning cycles, as well as the sustainability or generalizability of solutions. Some types of data have been consistently underrepresented, including patient-reported outcomes and preferences, social determinants, and behavioral and environmental data, the absence of which can exacerbate health disparities. A promising approach to addressing many challenges that LHSs face may be found in dissemination and implementation (D&I) science. With an emphasis on multilevel dynamic contextual factors, representation of implementation partner engagement, pragmatic research, sustainability, and generalizability, D&I science methods can assist in overcoming many of the challenges facing LHSs. In this article, the authors describe the current state of LHSs and challenges to becoming a mature LHS, propose solutions to current challenges, focusing on the contributions of D&I science with other methods, and propose key components and characteristics of a mature LHS model that others can use to plan and develop their LHSs.

The National Heart Lung and Blood Institute Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Alliance.

OBJECTIVE: To describe the National Heart Lung and Blood Institute (NHLBI) sponsored Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease (DECIPHeR) Alliance to support late-stage implementation research aimed at reducing disparities in communities with high burdens of cardiovascular and/or pulmonary disease. STUDY SETTING: NHBLI funded seven DECIPHeR studies and a Coordinating Center. Projects target high-risk diverse populations including racial and ethnic minorities, urban, rural, and low-income communities, disadvantaged children, and persons with serious mental illness. Two projects address multiple cardiovascular risk factors, three focus on hypertension, one on tobacco use, and one on pediatric asthma. STUDY DESIGN: The initial phase supports planning activities for sustainable uptake of evidence-based interventions in targeted communities. The second phase tests late-stage evidence-based implementation strategies. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: We provide an overview of the DECIPHeR Alliance and individual study designs, populations, and settings, implementation strategies, interventions, and outcomes. We describe the Alliance's organizational structure, designed to promote cross-center partnership and collaboration. CONCLUSIONS: The DECIPHeR Alliance represents an ambitious national effort to develop sustainable implementation of interventions to achieve cardiovascular and pulmonary health equity.

Pragmatic considerations and approaches for measuring staff time as an implementation cost in health systems and clinics: key issues and applied examples.

BACKGROUND: As the field of implementation science wrestles with the need for system decision-makers to anticipate the budget impact of implementing new programs, there has been a push to report implementation costs more transparently. For this purpose, the method of time-driven activity-based costing (TDABC) has been heralded as a pragmatic advance. However, a recent TDABC review found that conventional methods for estimating staff time remain resource-intensive and called for simpler alternatives. Our objective was to conceptually compare conventional and emerging TDABC approaches to measuring staff time. METHODS: Our environmental scan of TDABC methods identified several categories of approaches for staff time estimation; across these categories, staff time was converted to cost as a pro-rated fraction of salary/benefits. Conventional approaches used a process map to identify each step of program delivery and estimated the staff time used at each step in one of 3 ways: (a) uniform estimates of time needed for commonly occurring tasks (self-report), (b) retrospective "time diary" (self-report), or (c) periodic direct observation. In contrast, novel semi-automated electronic health record (EHR) approaches "nudge" staff to self-report time for specific process map step(s)-serving as a contemporaneous time diary. Also, novel EHR-based automated approaches include timestamps to track specific steps in a process map. We compared the utility of these TDABC approach categories according to the 5 R's model that measures domains of interest to system decision-makers: relevance, rapidity, rigor, resources, and replicability, and include two illustrative case examples. RESULTS: The 3 conventional TDABC staff time estimation methods are highly relevant to settings but have limited rapidity, variable rigor, are rather resource-intensive, and have varying replicability. In contrast to conventional TDABC methods, the semi-automated and automated EHR-based approaches have high rapidity, similar rigor, similar replicability, and are less resource-intensive, but have varying relevance to settings. CONCLUSIONS: This synthesis and evaluation of conventional and emerging methods for staff time estimation by TDABC provides the field of implementation science with options beyond the current approaches. The field remains pressed to innovatively and pragmatically measure costs of program delivery that rate favorably across all of the 5 R's domains.

Integrating a physical activity coaching intervention into diabetes care: a mixed-methods evaluation of a pilot pragmatic trial.

Physical activity (PA) counseling is under-utilized in primary care for patients with type 2 diabetes mellitus (T2D), despite improving important health outcomes, including physical function. We adapted evidence-based PA counseling programs to primary care patients, staff, and leader's needs, resulting in "Be ACTIVE" comprised of shared PA tracker data (FitBit©), six theory-informed PA coaching calls, and three in-person clinician visits. In a pilot randomized pragmatic trial, we evaluated the feasibility, acceptability, and effectiveness of Be ACTIVE. Sedentary patients with T2D were randomized to Be ACTIVE versus an enhanced control condition. Mixed methods assessments of feasibility and acceptability included costs. Objective pilot effectiveness outcomes included PA (primary outcome, accelerometer steps/week), the Short Physical Performance Battery (SPPB) physical function measure, and behavioral PA predictors. Fifty patients were randomized to Be ACTIVE or control condition. Acceptability was >90% for patients and clinic staff. Coaching and PA tracking costs of ~$90/patient met Medicare reimbursement criteria. Pre-post PA increased by ~11% (Be ACTIVE) and ~6% in controls (group difference: 1574 ± 4391 steps/week, p = .72). As compared to controls, Be ACTIVE participants significantly improved SPPB (0.9 ± 0.3 vs. -0.1 ± 0.3, p = .01, changes >0.5 points prevent falls clinically), and PA predictors of self-efficacy (p = .02) and social-environmental support (p < .01). In this pilot trial, Be ACTIVE was feasible and highly acceptable to stakeholders and yielded significant improvements in objective physical function consistent with lower fall risk, whereas PA changes were less than anticipated. Be ACTIVE may need additional adaptation or a longer duration to improve PA outcomes.

We report results from a pragmatic and behavioral theory-based physical activity (PA) coaching program, termed "Be ACTIVE," for patients with type 2 diabetes that was designed to improve PA and function for patients and to be reimbursable and feasible for primary care teams. As compared to those who did not receive coaching, patients who received Be ACTIVE had physical function improvements that lowered their risk of falls. Be ACTIVE was delivered with fidelity and was highly acceptable to the key primary care stakeholders of patients, clinic staff coaches, and clinicians. Patients particularly liked the focus on setting goals to do enjoyable activities, the accountability of wearing a PA monitor, and the support of their coach. Clinical care professionals felt that their role of encouraging behavior change (coach) and safety monitoring (clinician) aligned well with their clinical expertise, and was professionally rewarding. Coaches felt the program helped them guide many patients to overcome preexisting negative perceptions of PA and develop intrinsic motivations to be active. The costs of clinic coach time and PA tracker rental needed to deliver the 12-week program could be reimbursed by the Medicare Chronic Disease Management programs, albeit with a patient co-payment required.

Promoting rigor and sustainment in implementation science capacity building programs: A multi-method study.

Background: The field of Implementation science (IS) continues to evolve, and the number and type of IS capacity building Programs (ISCBPs) are in flux. These changes push the field to revisit the accepted IS competencies and to guide sustainment of ISCBPs. Our objectives were: (1) compare characteristics of current ISCBPs; (2) identify recommendations to support ISCBP sustainment; (3) measure how often ISCBPs address IS competencies; (4) identify novel and important IS competencies for the field. Method: This multi-method study included ISCBPs delivering structured, longitudinal IS training, excluding single courses and brief workshops. We used three complementary methods to meet our objectives. First, we identified ISCBPs via an internet search and snowball sampling methods. Second, we surveyed these ISCBPs to identify areas of program focus, types of trainees, IS competencies addressed, and recommendations to sustain ISCBPs. Third, we conducted a modified Delphi process with IS researchers/leaders to reach consensus on the IS competencies that were both important and novel as compared to the IS competencies published to date. Results: Among 74 eligible ISCBPs identified, 46 responded (62% response rate). Respondent ISCBPs represented diverse areas of focus (e.g., global health, cardiopulmonary disease) and trainee stages (e.g., graduate students, mid-career faculty). While most respondent ISCBPs addressed core IS methods, targeting IS competencies was less consistent (33% for nongraduate/non-fellowship ISCBPs; >90% for graduate/national ISCBPs). Our modified Delphi process identified eight novel and important IS competencies related to increasing health equity or the speed of translation. Recommendations to sustain ISCBPs included securing financial administrative support. Conclusions: Current ISCBPs train learners across varying career stages in diverse focus areas. To promote rigor, we recommend ISCBPs address specific IS competencies, with consideration of these eight novel/emerging competencies. We also recommend ISCBPs report on their IS competencies, focus area(s), and trainee characteristics. ISCBP programs need administrative financial support. Plain Language Summary: There is a limited workforce capacity to conduct implementation science (IS) research. To address this gap, the number and type of IS capacity building Programs (ISCBPs) focusing on training researchers and practitioners in IS methods continue to increase. Our efforts to comprehensively identify and describe ISCBPs for researchers and practitioners highlighted four implications for leaders of ISCBPs related to program sustainment and rigor. First, we identified a range of contextual characteristics of ISCBPs, including the research topics, methods, and IS competencies addressed, and the types of trainees accepted. Second, given the variability of trainee types and research, rigorous ISCBP programs should tailor the IS competencies and methods addressed to the skills needed by the types of trainees in their program. Third, the field of IS needs to periodically revisit the competencies needed with attention to the skills needed in the field. We used a consensus-building process with ISCBP leaders and other IS experts to expand existing IS competencies and identified eight important, novel IS competencies that broadly relate to promoting health equity and speeding the translation of research to practice. Finally, as more institutions consider developing ISCBPs, we identified factors needed to support ISCBP sustainment, including ongoing financial support. In addition to these implications for ISCBP leaders, there are also policy implications. For example, IS journals may enact policies to require manuscripts evaluating ISCBP performance to report on certain contextual characteristics, such as the IS competencies addressed and types of trainees accepted. The field may also consider developing an accreditation body to evaluate the rigor of ISCBP curricula.

Stakeholder input on a care planning tool to address unhealthy behaviors, mental health needs, and social risks: The value of different stakeholder perspectives.

This report describes how stakeholder groups informed a web-based care planning tool's development for addressing root causes of poor health. Stakeholders included community members (n = 6), researchers (n = 6), community care providers (n = 9), and patients (n = 17). Feedback was solicited through focus groups, semi-structured interviews, and user experience observations and then qualitatively analyzed to identify themes. Each group contributed a unique perspective. Researchers wanted evidence-based content; community members and providers focused on making goals manageable; patients wanted care team support and simple action-oriented language. Our findings highlight the benefits of stakeholder input. Blending perspectives from multiple groups results in a more robust intervention design.

Screening for Interpersonal Violence: Missed Opportunities and Potential Harms.

INTRODUCTION: Screening for interpersonal violence is used in healthcare settings to identify patients experiencing violence. However, using unvalidated screening tools may misclassify patients' experience with violence. The Center for Medicare & Medicaid Innovation adapted a previously validated intimate partner violence screening tool for use in assessing interpersonal violence and retained the tool's original scoring rubric, despite the new tool's broader scope. This study evaluates the scoring system for detecting safety concerns. METHODS: This was a cross-sectional survey of a convenience sample of adult patients and caregivers of pediatric patients at 7 primary care clinics and 4 emergency departments (2018-2019). Surveys included the adapted 4-item Hurt Insult Threat Scream tool. Questions are scored by frequency on a Likert scale (1=never; 5=frequently). Scores of 11-20 are considered positive for safety concerns. Two-sided Fisher's exact tests were used for descriptive analyses. Data analyses occurred in 2019-2020. RESULTS: Of 1,014 participants, 66 (6.5%) reported any frequency of physical violence. Of these, 54 (81.8%) did not reach the threshold score of 11. Of the 1,014 participants, 93 (9.2%) reported any frequency of physical violence or being threatened with harm; 76 of 93 participants (81.7%) scored <11. CONCLUSIONS: Using the original scoring criteria for the adapted Hurt Insult Threat Scream, >80% of participants reporting physical violence did not screen positive for potential safety concerns. The scoring criteria did not reliably identify participants experiencing or at high risk for violence. To improve patient safety, the adapted Hurt Insult Threat Scream scoring rubric should be updated on the basis of stakeholder input and additional validation studies.

Assessment of Social Risk Factors and Interest in Receiving Health Care-Based Social Assistance Among Adult Patients and Adult Caregivers of Pediatric Patients.

Importance: Health care organizations are increasingly incorporating social risk screening into patient care. Studies have reported wide variations in patients' interest in receiving health care-based assistance for identified social risks. However, no study to date has examined the factors associated with patients' interest in receiving assistance, including whether interest in receiving assistance varies based on specific patient demographic characteristics. Targeted research on this topic could improve the success of health care-based programs that offer social care services. Objective: To identify participant characteristics associated with interest in receiving health care-based social risk assistance. Design, Setting, and Participants: This cross-sectional study was conducted in 7 primary care clinics and 4 emergency departments in 9 US states between July 2, 2018, and February 13, 2019. A convenience sample of adult patients and adult caregivers of pediatric patients completed a screening survey that measured social risk factors and participants' interest in receiving assistance for identified social risks. Participants were randomly selected to receive 1 of 2 versions of the survey, which differed based on the order in which questions about social risks and interest in receiving assistance were presented. Multivariable logistic regression analyses were used to evaluate the associations between covariates and participants' interest in receiving assistance, stratified by social risk screening results. Data were analyzed from September 8, 2019, to July 30, 2020. Exposures: Social risk screening questions assessed risk factors comprising housing, food, transportation, utilities, and exposure to interpersonal violence. Additional questions assessed participants' interest in receiving assistance and their perspectives on health care-based social risk screening. Main Outcomes and Measures: Participant interest in receiving health care-based social risk assistance. Results: A total of 1021 adult participants with complete survey responses were included in the analysis. Of those, 709 of 1004 participants (70.6%) were female, and 544 of 1007 participants (54.0%) were aged 18 to 44 years. Overall, 353 of 662 participants (53.3%) with positive screening results for 1 or more social risk factors were interested in receiving assistance, whereas 31 of 359 participants (8.6%) with negative screening results for all social risks were interested in receiving assistance. Participants with positive screening results for 1 or more social risk factors had a higher likelihood of being interested in receiving assistance if they answered the question about interest in receiving assistance before they answered the questions about social risk factors (adjusted odds ratio [aOR], 1.48; 95% CI, 1.05-2.07), had positive screening results for a higher number of social risk factors (aOR, 2.40; 95% CI, 1.68-3.42), reported lower household income levels (aOR, 7.78; 95% CI, 2.96-20.44), or self-identified as having non-Hispanic Black ancestry (aOR, 2.22; 95% CI, 1.37-3.60). Among those with negative screening results for all social risk factors, the interest in receiving assistance was higher if the participants reported lower household income levels (aOR, 12.38; 95% CI, 2.94-52.15), previous exposure to health care-based social risk screening (aOR, 2.35; 95% CI, 1.47-3.74), higher perceived appropriateness of social risk screening (aOR, 3.69; 95% CI, 1.08-12.55), or worse health status (aOR, 4.22; 95% CI, 1.09-16.31). Conclusions and Relevance: In this study, multiple factors were associated with participants' interest in receiving social risk assistance. These findings may have implications for how and when social risk assistance is offered to patients. As the health care system's role in addressing social risk factors evolves, an understanding of patients' perspectives regarding screening and their interest in receiving assistance may be important to implementing patient-centered interventions.

Enhanced care planning and clinical-community linkages versus usual care to address basic needs of patients with multiple chronic conditions: a clinician-level randomized controlled trial.

BACKGROUND: Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients' needs, are often not included in these systems. METHODS: We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients' needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR. DISCUSSION: This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03885401. Registered on 19 September 2019.

Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers.

INTRODUCTION: Despite recent growth in healthcare delivery-based social risk screening, little is known about patient perspectives on these activities. This study evaluates patient and caregiver acceptability of social risk screening. METHODS: This was a cross-sectional survey of 969 adult patients and adult caregivers of pediatric patients recruited from 6 primary care clinics and 4 emergency departments across 9 states. Survey items included the Center for Medicare and Medicaid Innovation Accountable Health Communities' social risk screening tool and questions about appropriateness of screening and comfort with including social risk data in electronic health records. Logistic regressions evaluated covariate associations with acceptability measures. Data collection occurred from July 2018 to February 2019; data analyses were conducted in February‒March 2019. RESULTS: Screening was reported as appropriate by 79% of participants; 65% reported comfort including social risks in electronic health records. In adjusted models, higher perceived screening appropriateness was associated with previous exposure to healthcare-based social risk screening (AOR=1.82, 95% CI=1.16, 2.88), trust in clinicians (AOR=1.55, 95% CI=1.00, 2.40), and recruitment from a primary care setting (AOR=1.70, 95% CI=1.23, 2.38). Lower appropriateness was associated with previous experience of healthcare discrimination (AOR=0.66, 95% CI=0.45, 0.95). Higher comfort with electronic health record documentation was associated with previously receiving assistance with social risks in a healthcare setting (AOR=1.47, 95% CI=1.04, 2.07). CONCLUSIONS: A strong majority of adult patients and caregivers of pediatric patients reported that social risk screening was appropriate. Most also felt comfortable including social risk data in electronic health records. Although multiple factors influenced acceptability, the effects were moderate to small. These findings suggest that lack of patient acceptability is unlikely to be a major implementation barrier. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Part II: A Qualitative Study of Social Risk Screening Acceptability in Patients and Caregivers.

INTRODUCTION: This study aimed to better understand patient and caregiver perspectives on social risk screening across different healthcare settings. METHODS: As part of a mixed-methods multisite study, the authors conducted semistructured interviews with a subset of adult patients and adult caregivers of pediatric patients who had completed the Center for Medicare and Medicaid Innovation Accountable Health Communities social risk screening tool between July 2018 and February 2019. Interviews, conducted in English or Spanish, asked about reactions to screening, screening acceptability, preferences for administration, prior screening experiences that informed perspectives, and expectations for social assistance. Basic thematic analysis and constant comparative methods were used to code and develop themes. RESULTS: Fifty interviews were conducted across 10 study sites in 9 states, including 6 primary care clinics and 4 emergency departments. There was broad consensus among interviewees across all sites that social risk screening was acceptable. The following 4 main themes emerged: (1) participants believed screening for social risks is important; (2) participants expressed insight into the connections between social risks and overall health; (3) participants emphasized the importance of patient-centered implementation of social risk screening; and (4) participants recognized limits to the healthcare sector's capacity to address or resolve social risks. CONCLUSIONS: Despite gaps in the availability of social risk-related interventions in healthcare settings, patient-centered social risk screening, including empathy and attention to privacy, may strengthen relationships between patients and healthcare teams. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Expanding the CONSORT Figure: Increasing Transparency in Reporting on External Validity.

INTRODUCTION: There are major problems with failure to replicate research findings. Contributing to this problem is a failure to report on factors related to external validity. Frequently, researchers have little knowledge whether findings apply more generally, especially to low-resource settings and underserved populations. The CONSORT flow diagram has improved reporting on variables related to internal validity, but it has very limited detail on issues related to external validity. A recent CONSORT update and other publications have called for more transparent reporting on external validity and context, and information regarding the sustainability of interventions. All of these elements influence the generalizability of findings from outcomes research. METHODS: Drawing on theory, a prior meeting, and recent recommendations for reporting factors related to external validity, the authors propose an expansion of the basic CONSORT flow diagram for clinical trials to concisely summarize these data that recent CONSORT statements and other guidelines have recommended. RESULTS: The authors propose the use of an expanded CONSORT figure and illustrate its utility with an example. The expanded CONSORT figure adds data about participation and representativeness at the levels of settings and staff, and about intervention sustainability after project support ends. The authors provide an expanded CONSORT figure reporting template, and demonstrate its use. CONCLUSIONS: Improving transparent reporting on external validity by using the proposed expanded CONSORT figure would help to address both the scientific replication crisis and health equity concerns. This figure provides a method to efficiently address the representativeness, generalizability, and sustainability of outcomes research.

Identifying Motives of Midlife Black Triathlete Women Using Survey Transformation to Guide Qualitative Inquiry.

Demonstrating health disparities related to race, age, and gender, older Black women (BW) are the most sedentary demographic group in the United States. Increasing PA in mid-life is important, as it improves health as BW age into their later years. Advancing our understanding of the exercise motives of BW triathletes presents a "reverse engineering" opportunity to identify motives that could influence sedentary mid-life BW to increase their activity. The purposes of this study were to: (a) utilize an innovative survey transformation method to adapt a measure developed primarily in Caucasian males, i.e., the Motivations of Marathoners Scale for Triathletes (MOMS-T) into a qualitative interview guide for use with BW triathletes; (b) use this interview guide to identify culturally based motives for triathlon participation among BW not previously addressed by the MOMS-T and; (c) interpret the novel motivational domains of the MOMS-T discovered, in order to gain understanding and influence subsequent interventions. Purposive sampling was used to select 12 interview participants from 121 self-identified Black female US residents aged ≥36 years with recent experience completing or training for a triathlon. The interviews identified four culturally based themes, including improving body composition to become "more lean", physical attractiveness, triathlete family, and camaraderie. These novel themes were related to existing MOMS-T scales, but the current MOMS-T questions did not illuminate their culturally distinct aspects. The process of survey transformation provides a viable approach to identify important culturally based characteristics and to adapt surveys to cultural minority populations, particularly when study resources are limited.

"My hair or my health:" Overcoming barriers to physical activity in African American women with a focus on hairstyle-related factors.

Physical activity disparities among African American (AA) women may be related to sociocultural barriers, including difficulties with restyling hair after exercise. We sought to identify physical activity barriers and facilitators in AA women with a focus on sociocultural factors related to hairstyle maintenance. Participants (n = 51) were AA women aged 19-73 years who completed valid surveys and participated in structured focus groups, stratified by age and physical activity levels, from November 2012 to February 2013. The Constant Comparison method was used to develop qualitative themes for barriers and facilitators. The most frequently reported general physical activity barrier among exercisers was "lack of money" (27%) and among non-exercisers was "lack of self-discipline" (57%). A hairstyle-related barrier of "sweating out my hairstyle" was reported by 7% of exercisers and 29% of non-exercisers. This hairstyle-related barrier included the need for extra time and money to restyle hair due to perspiration. Hairstyle-related facilitators included: prioritizing health over hairstyle and high self-efficacy to restyle hair after perspiration. Participants were interested in resources to simplify hairstyle maintenance. AA women whose hairstyle is affected by perspiration may avoid physical activity due to time and financial burdens. Increasing self-efficacy to restyle hair after perspiration may help to overcome this barrier.

Physician Acceptance of a Physician-Pharmacist Collaborative Treatment Model for Hypertension Management in Primary Care.

Physician-pharmacist collaborative care (PPCC) is effective in improving blood pressure (BP) control, but primary care provider (PCP) engagement in such models has not been well-studied. The authors analyzed data from PPCC referrals to 108 PCPs, for patients with uncontrolled hypertension, assessing the proportion of referral requests approved, disapproved, and not responded to, and reasons for disapproval. Of 2232 persons with uncontrolled hypertension, PPCC referral requests were sent for 1516 (67.9%): 950 (62.7%) were approved, 406 (26.8%) were disapproved, and 160 (10.6%) received no response. Approval rates differed widely by PCP with a median approval rate of 75% (interquartile range, 41%-100%). The most common reasons for disapproval were: PCP prefers to manage hypertension (19%), and BP controlled per PCP (18%); 8% of cases were considered too complex for PPCC. Provider acceptance of a PPCC hypertension clinic was generally high and sustained but varied widely among PCPs. No single reason for disapproval predominated.

Missed opportunities for providing low-fat dietary advice to people with diabetes.

INTRODUCTION: Because cardiovascular disease is closely linked to diabetes, national guidelines recommend low-fat dietary advice for patients who have cardiovascular disease or are at risk for diabetes. The prevalence of receiving such advice is not known. We assessed the lifetime prevalence rates of receiving low-fat dietary advice from a health professional and the relationship between having diabetes or risk factors for diabetes and receiving low-fat dietary advice. METHODS: From 2002 through 2009, 188,006 adults answered the following question in the Medical Expenditure Panel Survey: "Has a doctor or other health professional ever advised you to eat fewer high-fat or high-cholesterol foods?" We assessed the association between receiving advice and the following predictors: a diabetes diagnosis, 7 single risk factors for type 2 diabetes, and total number of risk factors. RESULTS: Among respondents without diabetes or risk factors for diabetes, 7.4% received low-fat dietary advice; 70.6% of respondents with diabetes received advice. Respondents with diabetes were almost twice as likely to receive advice as respondents without diabetes or its risk factors. As the number of risk factors increased, the likelihood of receiving low-fat dietary advice increased. Although unadjusted advice rates increased during the study period, the likelihood of receiving advice decreased. CONCLUSION: Although most participants with diabetes received low-fat dietary advice, almost one-third did not. Low-fat dietary advice was more closely associated with the total number of diabetes risk factors than the presence of diabetes. Increasing rates of diabetes and diabetes risk factors are outpacing increases in provision of low-fat dietary advice.