Insights Into Patients' Perceptions of Health-Related Social Needs and the Role of the Adult Primary Care Clinic.

INTRODUCTION/OBJECTIVES: While it is well established that unmet healthrelated social needs (HRSN) adversely affect health outcomes, there has been limited evaluation in adult primary care of patients' perceptions of how these needs impact their health and the role of the primary care provider (PCP). The objective of this study is to identify patients' perceptions of HRSN and how PCPs could help address them. Secondary objectives include exploring the impact of goal setting and a 1-time cash transfer (CT). METHODS: This qualitative study used semi-structured baseline and follow-up interviews with patients in internal medicine clinics. Adult primary care patients were included if they screened positive as having 1 of 3 HRSN: financial resource strain, transportation needs, or food insecurity. All participants completed an initial interview about their HRSN and health, and were asked to set a 6-month health goal. At enrollment, participants were randomized to receive a $500 CT or a $50 participation reward. At 6-months, patients were interviewed again to investigate progress toward meeting their health goals, [when applicable] how the CT helped, and their beliefs about the role of PCPs in addressing HRSN. RESULTS: We completed 30 initial and 25 follow-up interviews. Participants identified their HRSN, however most did not readily connect identified needs to health. Although participants were receptive to HRSN screening, they did not feel it was their PCP's responsibility to address these needs. Verbal goal-setting appeared to be a useful tool, and while the CTs were appreciated, patients often found them inadequate to address HRSN. CONCLUSIONS: Given the importance of identifying the social conditions that shape patients' health, providers, and health systems have an opportunity to re-evaluate their role in helping patients address these barriers. Future studies could examine the effect of more frequent disbursement of CTs over time.

Feasibility of combining biosensor and ecological momentary assessment to measure stress experiences among economically disadvantaged adolescents.

Adolescent stress is complex and impairing. Novel measures are needed to understand stress variability within individuals over time from a physiological as well as a subjective perspective. To test the feasibility of combining ecological momentary assessment (EMA) and wearable biosensors to assess adolescent stress, using an idiographic approach with experience sampling methods. A small sample (n = 23) of predominantly African American, economically disadvantaged adolescents were asked to complete EMA surveys four times per day and wear an armband measuring Heart rate (HR) and skin response for a 2-week period. Descriptive analyses examined number of hours of armband wear, percentage of viable data, and percentage of surveys completed by gender and race. Associations between biosensor data and EMA reports within and across individuals were also examined using hierarchical linear regression. EMA survey completion was good (81%) as was adherence to biosensor protocols, although technological difficulties interfered with collection of HR variability for youth with darker skin tones. Youth reported stressful events in 12.79% of EMA surveys, although 43% reported no negative mood experiences. Convergent validity was supported for detecting between-person (EMA) and within-person (EMA and biosensors) variability in stress across time, although associations across youth were highly variable. Results suggest value for biobehavioral methods in understanding day-to-day stress in adolescents but highlight variability in stress experiences as well as technological limitations, especially for youth of colour.

Gender Differences in Retention and Promotion Among Generalists Who Graduated From Research-Intensive Fellowships.

BACKGROUND: Generalists who pursue research-intensive fellowships develop research skills and mentor-mentee relationships. Whether gender disparities in retention and promotion exist among this research-trained cohort is understudied. OBJECTIVE: We measured whether disparities exist among graduates of research-intensive fellowships and how mentorship influences them. METHODS: We surveyed generalists (internal medicine, pediatrics, family medicine, combined internal medicine-pediatrics) between July and August 2016 who graduated from research-intensive fellowships. Generalists ("mentees") were asked whether they remained or were promoted, and to name up to 10 influential mentors during or within 5 years of fellowship. Multivariable logistic regression estimated associations between mentee gender and retention and promotion. Next, we separately included 3 network characteristics: (1) mentee degrees (number of mentors reported per mentee); (2) mean mentor betweenness centrality (importance of each mentor within the network); and (3) largest community membership (mentee status in the largest interconnected mentor-mentee group within the network). All models adjusted for generalists' race, specialty, fellowship institution, and publications. RESULTS: One hundred sixty-two graduates (51%) representing 19 institutions responded. In adjusted analyses, compared to men, women were as likely to remain in academic medicine (odds ratio [OR] 1.88; 95% confidence interval [CI] 0.72-4.89; P = .20), but less likely to be promoted within 5 years of fellowship (OR 0.26; 95% CI 0.09-0.80; P = .018). Inclusion of network measures did not alter these associations. CONCLUSIONS: Despite remaining in academic medicine as frequently as their male counterparts, fellowship-trained women were promoted less often. Features of mentors, measured using network analysis, may not explain these observed differences.

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.

Beyond Books: Public Libraries As Partners For Population Health.

Public libraries are not usually included in discussions about improving population health. They are, however, well positioned to be partners in building a culture of health through programming that addresses the social determinants of health. The Healthy Library Initiative, a partnership between the University of Pennsylvania and the Free Library of Philadelphia (the public library system that serves the city), has undertaken such efforts in Philadelphia. In this article we report findings from an assessment of how ten highly subscribed programs address the social determinants of health, as well as results of interviews with community residents and library staff. Of the 5.8 million in-person Free Library visits in 2015, 500,000 included attendance at specialized programs that addressed multiple health determinants, such as housing and literacy. Library staff provided intensive support to vulnerable populations including homeless people, people with mental illness and substance use, recent immigrants, and children and families suffering from trauma. We found that public libraries are trusted institutions that have broad population reach and untapped potential to improve population health.

Penn Center for Community Health Workers: Step-by-Step Approach to Sustain an Evidence-Based Community Health Worker Intervention at an Academic Medical Center.

Community-engaged researchers who work with low-income communities can be reliant on grant funding. We use the illustrative case of the Penn Center for Community Health Workers (PCCHW) to describe a step-by-step framework for achieving financial sustainability for community-engaged research interventions. PCCHW began as a small grant-funded research project but followed an 8-step framework to engage both low-income patients and funders, determine outcomes, and calculate return on investment. PCCHW is now fully funded by Penn Medicine and delivers the Individualized Management for Patient-Centered Targets (IMPaCT) community health worker intervention to 2000 patients annually.

Assessment of the olfactory function in Italian patients with type 3 von Willebrand disease caused by a homozygous 253 Kb deletion involving VWF and TMEM16B/ANO2.

Type 3 Von Willebrand disease is an autosomal recessive disease caused by the virtual absence of the von Willebrand factor (VWF). A rare 253 kb gene deletion on chromosome 12, identified only in Italian and German families, involves both the VWF gene and the N-terminus of the neighbouring TMEM16B/ANO2 gene, a member of the family named transmembrane 16 (TMEM16) or anoctamin (ANO). TMEM16B is a calcium-activated chloride channel expressed in the olfactory epithelium. As a patient homozygous for the 253 kb deletion has been reported to have an olfactory impairment possibly related to the partial deletion of TMEM16B, we assessed the olfactory function in other patients using the University of Pennsylvania Smell Identification Test (UPSIT). The average UPSIT score of 4 homozygous patients was significantly lower than that of 5 healthy subjects with similar sex, age and education. However, 4 other members of the same family, 3 heterozygous for the deletion and 1 wild type, had a slightly reduced olfactory function indicating that socio-cultural or other factors were likely to be responsible for the observed difference. These results show that the ability to identify odorants of the homozygous patients for the deletion was not significantly different from that of the other members of the family, showing that the 253 kb deletion does not affect the olfactory performance. As other genes may compensate for the lack of TMEM16B, we identified some predicted functional partners from in silico studies of the protein-protein network of TMEM16B. Calculation of diversity for the corresponding genes for individuals of the 1000 Genomes Project showed that TMEM16B has the highest level of diversity among all genes of the network, indicating that TMEM16B may not be under purifying selection and suggesting that other genes in the network could compensate for its function for olfactory ability.

Quantitative assessment of nanoparticle surface hydrophobicity and its influence on pulmonary biocompatibility.

To date, the role of nanoparticle surface hydrophobicity has not been investigated quantitatively in relation to pulmonary biocompatibility. A panel of nanoparticles spanning three different biomaterial types, pegylated lipid nanocapsules, polyvinyl acetate (PVAc) and polystyrene nanoparticles, were characterized for size, surface charge, and stability in biofluids. Surface hydrophobicity of five nanoparticles (50-150nm) was quantified using hydrophobic interaction chromatography (HIC) and classified using a purpose-developed hydrophobicity scale: the HIC index, range from 0.00 (hydrophilic) to 1.00 (hydrophobic). This enabled the relationship between the nanomaterial HIC index value and acute lung inflammation after pulmonary administration to mice to be investigated. The nanomaterials with low HIC index values (between 0.50 and 0.64) elicited little or no inflammation at low (22cm(2)) or high (220cm(2)) nanoparticle surface area doses per animal, whereas equivalent surface area doses of the two nanoparticles with high HIC index values (0.88-0.96) induced neutrophil infiltration, elevation of pro-inflammatory cytokines and adverse histopathology findings. In summary, a HIC index is reported that provides a versatile, discriminatory, and widely available measure of nanoparticle surface hydrophobicity. The avoidance of high (HIC index>~0.8) surface hydrophobicity appears to be important for the design of safe nanomedicines for inhalation therapy.

Evaluating performance of and organisational capacity to deliver brief interventions in Aboriginal and Torres Strait Islander medical services.

OBJECTIVE: This study assessed brief intervention (BI) activity and organisation capacity for smoking, nutrition, alcohol and physical activity (SNAP framework) and key clinical prevention activities in four Aboriginal and Torres Strait Islander medical services in Queensland. METHODS: A mixed methods design was used including: staff surveys of knowledge and attitudes (n=39), focus groups to discuss perceived barriers and enablers and chart audits (n=150) to quantify existing BI activity. RESULTS: Of 50 clinical staff, 46 participated in the staff survey and focus groups across the four sites. BI was perceived to be important. There was significant variation in completion of records for SNAP risk factors, key clinical and BI activities across the sites. At least one SNAP factor status was recorded in 130/150 (86.7%) patient charts audited and there was a significant trend of increased recording of SNAP factors with increasing number of patient visits. Of those identified at risk 78% received at least one BI. Where risk was identified 65/96 (67.7%) patients required multiple BIs. BI for tobacco use was consistently high across all sites. Only one site recorded regular care planning and Adult Health Checks. Impacting factors included leadership, high staff turnover, multiple medical records and staff health status. CONCLUSIONS: Inflexible staff training, competing health priorities and high levels of staff turnover were identified as key barriers to the delivery of BI in clinical settings. The data suggests a good base of existing BI activity for smoking and key clinical activities which may improve with further support.