"Everyone's struggling right now": Impact of COVID-19 on addressing food insecurity in rural primary care.

BACKGROUND: Primary care practices can address food insecurity (FI) through routine screening, practice-based food programmes, and referrals to community resources. The COVID-19 pandemic had disproportionate impacts on health outcomes for food-insecure households. OBJECTIVE: To describe the impact of the COVID-19 pandemic on FI screening and interventions in rural primary care practices in northern New England. METHODS: We conducted semi-structured interviews with thirteen providers and staff regarding changes to FI screening and interventions, community resources and partnerships, and patient food needs during the pandemic. Themes and exemplar quotations were identified through iterative discussion. RESULTS: Practices reported more frequent informal discussions with patients about FI during the pandemic. Despite limitations in site operations, practices created programmes to distribute food at practice locations or through food deliveries. The adoption of telemedicine had variable impacts on FI screening, creating challenges for some while facilitating screening outside of scheduled visits for others. Practices reported increased food availability due to new or expanded community programmes, but lack of transportation and delivery availability were challenges. New and stronger connections formed between practices and community partners. Increased awareness of FI among both patients and practice staff resulted in decreased stigma. CONCLUSION: Screening for and addressing FI was a priority for rural primary care practices during the pandemic. The implementation of practice-based FI interventions was supported by stronger practice-community connections and a decrease in stigma. The experiences of providers and staff during the pandemic provide insight into best practices for engaging primary care practices in reducing FI.

A Peer-Based Strategy to Overcome HPV Vaccination Inequities in Rural Communities: A Physical Distancing-Compliant Approach.

The human papilloma virus (HPV) vaccine is the world's first proven and effective vaccine to prevent cancers in males and females when administered pre-exposure. Like most of the US, barely half of Vermont teens are up-to-date with the vaccination, with comparable deficits in New Hampshire and Maine. The rates for HPV vaccine initiation and completion are as low as 33% in rural New England. Consequently, there is a compelling responsibility to communicate its importance to unvaccinated teenagers before their risk for infection increases. Messaging in rural areas promoting HPV vaccination is compromised by community-based characteristics that include access to appropriate medical care, poor media coverage, parental and peer influence, and skepticism of science and medicine. Current strategies are predominantly passive access to literature and Internet-based information. Evidence indicates that performance-based messaging can clarify the importance of HPV vaccination to teenagers and their parents in rural areas. Increased HPV vaccination will significantly contribute to the prevention of a broadening spectrum of cancers. Reducing rurality-based inequities is a public health priority. Development of a performance-based peer-communication intervention can capture a window of opportunity to provide increasingly effective and sustained HPV protection. An effective approach can be partnering rural schools and regional health teams with a program that is nimble and scalable to respond to public health policies and practices compliant with COVID-19 pandemic-related modifications on physical distancing and interacting in the foreseeable future.

Assessing and Identifying Improvements for Lung Cancer Screening in a Rural Population: A Human-Centered Design and Systems Approach.

Although lung cancer claims more lives than any other cancer in the United States, screening is severely underutilized, with <6% of eligible patients screened nationally in 2021 versus 76% for breast cancer and 67% for colorectal cancer. This article describes an effort to identify key reasons for the underutilization of lung cancer screening in a rural population and to develop interventions to address these barriers suitable for both a large health system and local community clinics. Data were generated from 26 stakeholder interviews (clinicians, clinical staff, and eligible patients), a review of key systems (Electronic Health Record and billing records), and feedback on the feasibility of several potential interventions by health care system staff. These data informed a human-centered design approach to identify possible interventions within a complex health care system by exposing gaps in care processes and electronic health record platforms that can lead patients to be overlooked for potentially life-saving screening. Deployed interventions included communication efforts focused on (1) increasing patient awareness, (2) improving physician patient identification, and (3) supporting patient management. Preliminary outcomes are discussed.

Sexual and Reproductive Health Content in the 3 Ps in Nurse Practitioner Education.

BACKGROUND: Nurse practitioners (NPs) in primary care provide sexual and reproductive health care, an integral component of health and well-being. This study explored the degree of inclusion of sexual and reproductive health content in the foundational courses in NP preparation including advanced health assessment, advanced physiology and pathophysiology, and advanced pharmacology, known as the 3 Ps. METHOD: Qualitative interviews were conducted with 30 NPs in their first 2 years of practice. RESULTS: Sexual and reproductive health content was well integrated into advanced assessment courses, although participants wanted more comfort and skill with discussing sensitive sexual health issues. Advanced pharmacology and advanced pathophysiology courses were not likely to include the content. CONCLUSION: Interactive learning opportunities, such as simulation with feedback, promote communication skills with sensitive health issues. Foundational courses would benefit from a deeper understanding of the menstrual cycle, sexual functioning, and medications specific to sexual and reproductive health. [J Nurs Educ. 2022;61(3):131-136.].

The key to successful NP transition to practice.

ABSTRACT: This article explores the experiences of the new NP's onboarding process based on data from two qualitative studies. Interviews with 27 new graduates were used to inform the design, implementation, and experience of an onboarding program in a small healthcare setting without robust internal resources or a human resource department.

Did I learn enough to practice? Reflections of new nurse practitioner graduates in providing sexual and reproductive health care.

BACKGROUND: The Centers for Disease Control and Prevention and the US Office of Population Health have published guidelines for providing family planning services. PURPOSE: The study explores how nurse practitioners (NPs) perceived their preparation and competency in providing a range of sexual and reproductive health care in their first two years of community-based practice. METHODOLOGICAL ORIENTATION: Qualitative. Thematic analysis used to analyze data from structured and open-ended interview questions. SAMPLE: Through snowballing recruitment, 35 NPs participated in interviews. CONCLUSIONS: Participants were most confident and likely to provide contraceptive and sexually transmitted infection services. Participants felt less prepared to provide male sexual health and care to the lesbian, gay, bisexual, transgender, queer, and intersex+ population. Nurse practitioners expressed interest in building skills with discussing healthy sexuality across the life span, specifically postmenopausal sexual concerns, teen sexuality, trauma-informed care related to sexual violence, and early pregnancy decision making. Some participants had little preparation in early pregnancy decision making/options counseling. Faculty need to examine barriers to teaching these skills because the curriculum should address all legal pregnancy options, including discussing the NP's professional obligations. More preparation was needed in the clinical management of erectile dysfunction, polycystic ovary syndrome, herpes, syphilis, abnormal uterine bleeding, dyspareunia, pelvic pain, miscarriage management, and how to discuss prostate cancer screening. IMPLICATIONS FOR PRACTICE: The recommendations of the quality family planning, with additions, form a sound basis for sexual and reproductive health care standards, education, and clinical practice, should be part of NP education.

Smoke-Free Moms: Financial Rewards for Smoking Cessation by Low-Income Rural Pregnant Women.

INTRODUCTION: Maternal smoking places the child at risk during pregnancy and postpartum. Most women who quit smoking do so early when they first learn of pregnancy. Few low-income women quit once they enter prenatal care. The purpose of this study is to test in a clinical prenatal care setting the effectiveness of the Smoke-Free Moms intervention, which provides pregnant women a series of financial incentives for smoking cessation. STUDY DESIGN: A prospective nonrandomized controlled trial that collected control population data of smoking-cessation rates at each clincal visit during pregnancy and postpartum with usual smoking counseling in 2013-2014. In 2015-2016, the same data were collected during the implementation of the Smoke-Free Moms intervention of financial incentives. Data analysis occurred in 2017. SETTING/PARTICIPANTS: Women who were smoking at the first prenatal visit at four federally qualified health centers in rural New Hampshire. INTERVENTION: All women received 5A's smoking counseling from clinic staff. At each clinic visit, with point-of-care confirmed negative urinary cotinine, intervention women received gift cards. MAIN OUTCOME MEASURES: Cotinine confirmed smoking cessation without relapse: (1) during pregnancy and (2) smoking cessation in both pregnancy and postpartum. RESULTS: Of 175 eligible pregnant women enrolled, 134 women were followed to the postpartum visit (Intervention n=66, Control n=68). The quit rates during pregnancy did not differ between groups (Intervention 36.4%, Control 29.4%, p=0.46). However, significantly more intervention mothers quit and continued as nonsmokers postpartum (Intervention 31.8%, Control 16.2%, p=0.04). In a logistic regression model including baseline sociodemographic, depressed mood, stress, and readiness to quit items, confidence in being able to quit predicted both cessation outcomes. The financial incentive intervention was an independent predictor of cessation in pregnancy through postpartum. CONCLUSIONS: Financial incentives with existing smoking-cessation counseling by staff in low-income clinical prenatal programs led to cessation that continued during the postpartum period. Further study in larger populations is indicated.

Investigation of factors influencing the implementation of two shared decision-making interventions in contraceptive care: a qualitative interview study among clinical and administrative staff.

BACKGROUND: There is limited evidence on how to implement shared decision-making (SDM) interventions in routine practice. We conducted a qualitative study, embedded within a 2 × 2 factorial cluster randomized controlled trial, to assess the acceptability and feasibility of two interventions for facilitating SDM about contraceptive methods in primary care and family planning clinics. The two SDM interventions comprised a patient-targeted intervention (video and prompt card) and a provider-targeted intervention (encounter decision aids and training). METHODS: Participants were clinical and administrative staff aged 18 years or older who worked in one of the 12 clinics in the intervention arm, had email access, and consented to being audio-recorded. Semi-structured telephone interviews were conducted upon completion of the trial. Audio recordings were transcribed verbatim. Data collection and thematic analysis were informed by the 14 domains of the Theoretical Domains Framework, which are relevant to the successful implementation of provider behaviour change interventions. RESULTS: Interviews (n = 29) indicated that the interventions were not systematically implemented in the majority of clinics. Participants felt the interventions were aligned with their role and they had confidence in their skills to use the decision aids. However, the novelty of the interventions, especially a need to modify workflows and change behavior to use them with patients, were implementation challenges. The interventions were not deeply embedded in clinic routines and their use was threatened by lack of understanding of their purpose and effect, and staff absence or turnover. Participants from clinics that had an enthusiastic study champion or team-based organizational culture found these social supports had a positive role in implementing the interventions. CONCLUSIONS: Variation in capabilities and motivation among clinical and administrative staff, coupled with inconsistent use of the interventions in routine workflow contributed to suboptimal implementation of the interventions. Future trials may benefit by using implementation strategies that embed SDM in the organizational culture of clinical settings.

Right For Me: protocol for a cluster randomised trial of two interventions for facilitating shared decision-making about contraceptive methods.

INTRODUCTION: Despite the observed and theoretical advantages of shared decision-making in a range of clinical contexts, including contraceptive care, there remains a paucity of evidence on how to facilitate its adoption. This paper describes the protocol for a study to assess the comparative effectiveness of patient-targeted and provider-targeted interventions for facilitating shared decision-making about contraceptive methods. METHODS AND ANALYSIS: We will conduct a 2×2 factorial cluster randomised controlled trial with four arms: (1) video+prompt card, (2) decision aids+training, (3) video+prompt card and decision aids+training and (4) usual care. The clusters will be clinics in USA that deliver contraceptive care. The participants will be people who have completed a healthcare visit at a participating clinic, were assigned female sex at birth, are aged 15-49 years, are able to read and write English or Spanish and have not previously participated in the study. The primary outcome will be shared decision-making about contraceptive methods. Secondary outcomes will be the occurrence of a conversation about contraception in the healthcare visit, satisfaction with the conversation about contraception, intended contraceptive method(s), intention to use a highly effective method, values concordance of the intended method(s), decision regret, contraceptive method(s) used, use of a highly effective method, use of the intended method(s), adherence, satisfaction with the method(s) used, unintended pregnancy and unwelcome pregnancy. We will collect study data via longitudinal patient surveys administered immediately after the healthcare visit, four weeks later and six months later. ETHICS AND DISSEMINATION: We will disseminate results via presentations at scientific and professional conferences, papers published in peer-reviewed, open-access journals and scientific and lay reports. We will also make an anonymised copy of the final participant-level dataset available to others for research purposes. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT02759939.