Project nature: promoting outdoor physical activity in children via primary care.

BACKGROUND: Families face a range of barriers in supporting their children's active play in nature including family circumstances, environmental constraints, and behavioral factors. Evidence-based strategies to address these barriers are needed. We aimed to develop and pilot test a primary care-based family-centered behavioral intervention to promote active outdoor play in 4-10 year-old children. METHODS: Project Nature, a provider-delivered intervention that provides informational resources and an age-appropriate toy for nature play, was initially developed for children ages 0-3. With stakeholder input, we adapted existing materials for 4-10 year-olds and conducted usability testing at an urban clinic serving families from diverse backgrounds. Subsequently, we conducted a mix-methods pilot study to evaluate intervention feasibility and acceptability. Parents of 4-10 year-olds completed pre- and post-surveys (n = 22), and a purposive subset (n = 10) completed qualitative interviews. Post-intervention, pediatric providers (n = 4) were interviewed about their implementation experiences. RESULTS: The majority (82%) of parents liked the information provided and the remaining (18%) were neutral. Qualitatively, parents reported that: the toy provided a tangible element to help children and parents be active, they did not use the website, and they wished the intervention emphasized strategies for physical activity during cold and wet seasons. Providers felt the materials facilitated discussion about behavior change with families. There were no statistically significant changes in PA and outdoor time pre- and post-intervention. CONCLUSIONS: Project Nature was welcomed by providers and families and may be a practical intervention to promote outdoor active play during well-child visits. Providing an age-appropriate nature toy seemed to be a critical component of the intervention, and may be worth the additional cost, time and storage space required by clinics. Building from these results, Project Nature should be revised to better support active outdoor play during suboptimal weather and evaluated to test its efficacy in a fully-powered trial.

A sequential, multiple assignment randomized trial comparing web-based education to mobile video interpreter access for improving provider interpreter use in primary care clinics: the mVOCAL hybrid type 3 study protocol.

BACKGROUND: Individuals who use a language other than English for medical care are at risk for disparities related to healthcare safety, patient-centered care, and quality. Professional interpreter use decreases these disparities but remains underutilized, despite widespread access and legal mandates. In this study, we compare two discrete implementation strategies for improving interpreter use: (1) enhanced education targeting intrapersonal barriers to use delivered in a scalable format (interactive web-based educational modules) and (2) a strategy targeting system barriers to use in which mobile video interpreting is enabled on providers' own mobile devices. METHODS: We will conduct a type 3 hybrid implementation-effectiveness study in 3-5 primary care organizations, using a sequential multiple assignment randomized trial (SMART) design. Our primary implementation outcome is interpreter use, calculated by matching clinic visits to interpreter invoices. Our secondary effectiveness outcome is patient comprehension, determined by comparing patient-reported to provider-documented visit diagnosis. Enrolled providers (n = 55) will be randomized to mobile video interpreting or educational modules, plus standard interpreter access. After 9 months, providers with high interpreter use will continue as assigned; those with lower use will be randomized to continue as before or add the alternative strategy. After another 9 months, both strategies will be available to enrolled providers for 9 more months. Providers will complete 2 surveys (beginning and end) and 3 in-depth interviews (beginning, middle, and end) to understand barriers to interpreter use, based on the Theoretical Domains Framework. Patients who use a language other than English will be surveyed (n = 648) and interviewed (n = 75) following visits with enrolled providers to understand their experiences with communication. Visits will be video recorded (n = 100) to assess fidelity to assigned strategies. We will explore strategy mechanism activation to refine causal pathway models using a quantitative plus qualitative approach. We will also determine the incremental cost-effectiveness of each implementation strategy from a healthcare organization perspective, using administrative and provider survey data. DISCUSSION: Determining how these two scalable strategies, alone and in sequence, perform for improving interpreter use, the mechanisms by which they do so, and at what cost, will provide critical insights for addressing a persistent cause of healthcare disparities. TRIAL REGISTRATION: NCT05591586.

Qualitative Assessment of the Quality of Care for Preterm, Low Birth Weight, and Sick Newborns in Ethiopia.

This study assesses the quality of care for preterm, low birth weight (LBW), and sick newborns across the public health care system levels in 3 regions of Ethiopia. Qualitative data based on the WHO framework to assess provision and experience of care was collected using in-depth interviews and focus group discussions with women who recently delivered preterm, LBW, and sick newborns, as well as health care providers and health extension workers, and facility administrators associated with study health facilities. This qualitative approach revealed perspectives of patients, health care providers and facility administrators to assess what is actually happening in facilities. Clinical guidelines for the care of preterm, LBW, and sick newborns were not available in many facilities, and even when available, often not followed. Most providers reported little or no communication with parents following hospital discharge. Human resource challenges (shortage of skilled staff, motivation and willingness, lack of supervision, and poor leadership) inhibited quality of care. Participants reported widespread shortages of equipment and supplies, medication, physical space, water, electricity, and infrastructure. Economic insecurity was a critical factor affecting parents' experience. Acceptance by users was impacted by the perceived benefits and cost. Users reported they were less likely to accept interventions if they perceived that there would be financial costs they couldn't afford. The quality of care for preterm, LBW, and sick newborns in Ethiopia as reported by recently delivered women, health care providers and facility administrators is compromised. Improving quality of care requires attention to process of care, experience of care, and health system capacity, structure, and resources.

Referral systems for preterm, low birth weight, and sick newborns in Ethiopia: a qualitative assessment.

BACKGROUND: A responsive and well-functioning newborn referral system is a cornerstone to the continuum of child health care; however, health system and client-related barriers negatively impact the referral system. Due to the complexity and multifaceted nature of newborn referral processes, studies on newborn referral systems have been limited. The objective of this study was to assess the barriers for effective functioning of the referral system for preterm, low birth weight, and sick newborns across the primary health care units in 3 contrasting regions of Ethiopia. METHODS: A qualitative assessment using interviews with mothers of preterm, low birth weight, and sick newborns, interviews with facility leaders, and focus group discussions with health care providers was conducted in selected health facilities. Data were coded using an iteratively developed codebook and synthesized using thematic content analysis. RESULTS: Gaps and barriers in the newborn referral system were identified in 3 areas: transport and referral communication; availability of, and adherence to newborn referral protocols; and family reluctance or refusal of newborn referral. Specifically, the most commonly noted barriers in both urban and rural settings were lack of ambulance, uncoordinated referral and return referral communications between providers and between facilities, unavailability or non-adherence to newborn referral protocols, family fear of the unknown, expectation of infant death despite referral, and patient costs related to referral. CONCLUSIONS: As the Ethiopian Federal Ministry of Health focuses on averting early child deaths, government investments in newborn referral systems and standardizing referral and return referral communication are urgently needed. A complimentary approach is to lessen referral overload at higher-level facilities through improvements in the scope and quality of services at lower health system tiers to provide basic and advanced newborn care.

Adolescent and parent perspectives on the acceptability of financial incentives to promote self-care in adolescents with type 1 diabetes.

BACKGROUND: An understanding of acceptability among potential intervention participants is critical to the design of successful real-world financial incentive (FI) programs. The purpose of this qualitative study was to explore adolescent and parent perspectives on the acceptability of using FI to promote engagement in diabetes self-care in adolescents with type 1 diabetes (T1D). METHODS: Focus groups with 46 adolescents with T1D (12-17 years old) and 39 parents of adolescents with T1D were conducted in the Seattle metropolitan area. Semistructured questions addressed participants' current use of incentives to promote change in diabetes self-care and receptivity to a theoretical incentive program administered by a third-party. Qualitative data were analyzed and emergent themes identified. RESULTS: Three thematic categories informed participant views about the acceptability of FI programs: (a) the extent to which using FIs in the context of diabetes management fit comfortably into a family's value system, (b) the perceived effectiveness for FIs to promote improved diabetes self-care, and (c) the urgent need for improved self-care due to the threat of diabetes-related health complications. These factors together led most parents and adolescents to be open to FI program participation. CONCLUSIONS: The results from this qualitative study suggest that well-designed FI programs to support diabetes management are acceptable to families with adolescents with T1D. Additionally, the use of FIs may have the potential to support adolescents with T1D in developing strong self-care habits and ease the often-turbulent transition to independent self-care.

Health system readiness to support facilities for care of preterm, low birth weight, and sick newborns in Ethiopia: a qualitative assessment.

BACKGROUND: Preterm birth is a worldwide challenge with the highest burden in low- and middle-income countries. Despite availability of low-cost interventions to decrease mortality of preterm, low birth weight, and sick newborns, these interventions are not well integrated in the health systems of low- and middle-income countries. The aim of this study was to assess, from the perspective of key stakeholders comprising leaders in the public health system, the health system readiness to support health care facilities in the care provided to preterm, low birth weight, and sick newborns in different regions of Ethiopia. METHODS: A qualitative assessment using in-depth interviews with health facility leaders was conducted in health facilities in 3 regions of Ethiopia from December 2017 to February 2018. The interview guide was developed using a modified version of the World Health Organization health system building blocks. RESULTS: Across the public health system, adequate and reliable space, power, and water were problematic. Human resource issues (training, staffing, and retention) were critical to being able to properly care for preterm, low birth weight, and sick newborns. Problems with functional equipment and equipment distribution systems were widespread. Funds were lacking to support preterm, low birth weight, and sick newborn needs in facilities. Data collection practices, data quality, and data utilization were all problematic. There were gaps in the availability of guidelines and protocols, specifically targeting preterm, low birth weight, and sick newborn care. Key facilitators, information disseminators, and influencers identified in the study were the Health Development Army, community and religious leaders, and mothers and families who had had positive experiences or outcomes of care. CONCLUSIONS: The Ethiopian health system has opportunities across all 7 World Health Organization health system building blocks to strengthen readiness to support health facilities to provide quality care and improve outcomes for preterm, low birth weight, and sick newborns.

Dental health aides in Alaska: A qualitative assessment to improve paediatric oral health in remote rural villages.

OBJECTIVE: Isolated villages in Alaska face disparities in oral health and access to care. Dental health aides such as the primary dental health aide (PDHA) and the dental health therapist (DHAT) fill a critical role for providing dental care in Alaska. Our objective was to describe strengths and barriers to paediatric dental care for children living in remote Alaska villages from the perspectives of the community and the health care system. METHODS: This qualitative study collected data through semi-structured key informant interviews with community members (n = 19) and healthcare workers (n = 19) and focus groups with patients (n = 31 adolescents and 16 caregivers of children under 12 years) living in or providing health care to 3 remote villages in Alaska. Using an inductively developed codebook and a narrative approach, 3 researchers independently read and thematically analysed the transcripts. RESULTS: Two themes emerged: (i) PDHAs and DHATs are perceived as sustainable and strongly positioned to meet the unique dental needs of the rural communities; (ii) PDHAs and DHATs face barriers that limit their effectiveness, and their distinct roles require clarification and administrative support. CONCLUSIONS: Dental health aides, both PDHAs and DHATs, are well accepted in Alaska villages. An innate understanding of cultural norms and continuity of care are key elements driving village satisfaction. The potential exists administratively to strengthen the model with the implementation of clinical and office-system strategies to increase efficiency of the dental team. Culturally adapted implementation strategies will be critical to the successful expansion of new workforce models that are addressing health disparities.

Understanding the experiences of lesbian, bisexual and trans survivors of domestic violence: a qualitative study.

OBJECTIVES: Using a participatory approach, our objectives were to understand community perspectives on domestic violence (DV) in lesbian, bisexual and trans (LBT) communities, and to assess access to and cultural appropriateness ofDVservices for LBT survivors. METHODS: We used qualitative methods and conducted focus groups and semi-structured interviews with LBT survivors of DV. RESULTS: Nearly all participants reported that the level of awareness regarding DV in their communities was limited. Survivors reported difficulty identifying their partners' behavior as abusive. Isolation was described as central to experiences of abuse, and respondents discussed a variety of isolation tactics specific to LBT communities. Isolation also contributed to difficulty seeking help. Respondents reported that they often did not access mainstream DV services due to concerns about homophobia and transphobia. To address DV in LBT communities respondents pointed to the importance of friendship and community networks, sharing information about queer DV, and holding batterers accountable for their behavior. CONCLUSIONS: LBT people face challenges identifying and responding to DV that are specific to their cultural context. Services for LBT DV survivors must be culturally appropriate and accessible. Community based solutions for addressing and preventing DV should be encouraged.

"Women must endure according to their karma": Cambodian immigrant women talk about domestic violence.

Asian populations living in the United States share similar cultural values that influence their experiences with domestic violence. However, it is critical to recognize how differential cultural beliefs in the context of immigration and adjustment to life in the United States affect attitudes, interpretations, and response to domestic violence. This article discusses findings from community-based participatory action research that explores how Cambodian immigrant women talk about domestic violence, what forms of abuse contribute to domestic violence, and what strategies they use to cope with and respond to abuse in their lives. The richness of this research lies in the stories that immigrant women tell about their struggle and their strength in addressing domestic violence.

"For us it is like living in the dark": Ethiopian women's experiences with domestic violence.

This article discusses the experiences of domestic violence among Ethiopian refugees and immigrants in the United States. A subset (n=18) of the larger study sample (N=254) participated in three focus groups with Amharic-speaking survivors of domestic violence who were currently in or had left abusive relationships. The research was conducted through a public health department, University, and community agency partnership. Findings show domestic violence as taking place within a context of immigration, acculturation, and rapid changes in family and social structure. Participants expressed a need for language and culture-specific domestic violence support and advocacy as well as education programs regarding U.S. laws and resources.

"No way out": Russian-speaking women's experiences with domestic violence.

This article explores the experience of domestic violence and utilization of domestic violence resources among immigrant women who were Russian speaking. Participants, many of whom came to the United States as so-called mail-order brides, reported diverse forms of abuse, including isolation and financial restrictions, and were reluctant to get outside help because of embarrassment about their circumstances. Survivors stressed the importance of language- and culture-appropriate outreach and services and urged that women receive information about domestic violence services and laws on immigration. Assistance with housing, child care, and job searches is integral to safe transitions out of abusive relationships.

"Like a bird in a cage": Vietnamese women survivors talk about domestic violence.

In recent years, a growing literature has emerged that explores the role of culture in domestic violence for ethnic minority populations, including immigrants and refugees. This article presents qualitative data collected from Vietnamese refugee women through a research project in partnership with the Refugee Women's Alliance in Seattle, Washington. Through the women's stories, their own self-awareness of domestic violence as Vietnamese women residing in the United States is available for reflection and review. Issues of acculturation, changing gender roles, examples of strength, and cultural persistence constitute the thematic structure within which these women articulate their needs for creating and sustaining a life free of abuse for themselves and their children.

Addressing urban health in Detroit, New York City, and Seattle through community-based participatory research partnerships.

OBJECTIVE: This study describes key activities integral to the development of 3 community-based participatory research (CBPR) partnerships. METHODS: We compared findings from individual case studies conducted at 3 urban research centers (URCs) to identify crosscutting adaptations of a CBPR approach in the first 4 years of the partnerships' development. RESULTS: Activities critical in partnership development include sharing decision-making, defining principles of collaboration, establishing research priorities, and securing funding. Intermediate outcomes were sustained CBPR partnerships, trust within the partnerships, public health research programs, and increased capacity to conduct CBPR. Challenges included the time needed for meaningful collaboration, concerns regarding sustainable funding, and issues related to institutional racism. CONCLUSIONS: The URC experiences suggest that CBPR can be successfully implemented in diverse settings.

Using community-based participatory research to address social determinants of health: lessons learned from Seattle Partners for Healthy Communities.

Seattle Partners for Healthy Communities (SPHC) is a multidisciplinary collaboration of community agencies, community activists, public health professionals, academics, and health providers who conduct research aimed at improving the health of urban, socioeconomically marginalized Seattle communities. SPHC uses a community-based participatory research approach to address social factors that affect the health of these communities. This article describes three SPHC projects that focus on social determinants of health, particularly the development of social support and improving housing quality. The characteristics of community participation in each of these projects are discussed and show a spectrum of participation. Although projects successfully addressed proximal social factors affecting health, influencing more distal underlying factors was more difficult. Implications for researchers using a community-based participatory research approach and public health practitioners seeking to engage communities in addressing social determinants of health are presented.