Selecting patient-reported outcome measures of health-related quality of life in adult rheumatology: quality and breadth of coverage.

Patient-centered research should assess outcomes important to patients and include patient-reported outcome measures (PROMs) to assess health-related quality of life (HRQOL) domains. Using a well-known HRQOL framework (World Health Organization QOL, or WHOQOL), we reviewed established PROMs used with adults with different types of arthritis to evaluate their HRQOL domain coverage and psychometric evidence to help PROM users select measures and determine whether other measures should be validated and/or developed. Nineteen PROMs and 92 corresponding articles were reviewed to determine which HRQOL domains were assessed. To support a streamlined but rigorous review, we used a rating system based on criteria established in part through existing rubrics (e.g., OMERACT COSMIN). Psychometric properties were rated on a scale from 1 to 18, where 18 was strongest. We examined the intersection between level of domain coverage and extent of psychometric support. Measures most commonly assessed physical health and level of independence, while fewer assessed social relations, environment, and psychological health. No measures assessed spirituality and religion, which may be relevant depending on intended use. PROMs with higher psychometric evidence tended to assess a broader range of HRQOL domains. Rubric scores ranged from 3 to 16, with an average of 9.3. Prominent and psychometrically sound PROMs are available that cover many of the WHOQOL domains. While gaps exist in the domain of spirituality, future work should focus on refining optimal use of existing PROMs relevant for arthritis versus developing new measures. We provide guidance on selecting PROMs, to that end.

Inequitable access to sport in juvenile justice across the USA: findings from a national survey.

The USA incarcerates more young people than any other industrialized nation in the world, and black youth are much more likely to be incarcerated than white youth. Young people who interface with the criminal justice system are at higher risk for poor health upon release and the justice system is believed to be a contributor to racial health disparities. Sport participation during incarceration has the potential to improve health and health equity, but the evidence on the health benefits of youth sport participation has almost exclusively focused on school and community settings in the USA with little attention to non-traditional settings, such as the justice system. Given the poor health consequences of incarceration, the potential of sport to improve health, and the lack of research on this phenomenon in the USA, our objective was to describe the landscape of sport programming in juvenile correctional facilities and provide a baseline understanding upon which future research can build. Through a cross-sectional survey of all long-term secure juvenile correctional facilities in the USA (n = 211), we found 55.1% operate a sport program. Among facilities with programs, there was a range of sport program offerings. Gender disparities in access to various types of programs exist, with girls generally having less opportunity than boys. Most facilities reported a purpose of positive youth development in the operation of their programs. These findings have important implications for health promotion and the further integration of sport and juvenile justice as part of a public health agenda.

In the USA, we have more young people in prison than anywhere in the world. Time in prison is linked with a wide range of negative consequences, including worse health. Research on young people in general shows that participating in sports has the potential to protect them from a range of risky behaviors and can improve their health. It follows that sports in prison may help to protect those particularly at-risk youth from the negative health consequences of incarceration. Because so little is known about the availability of sport programs in youth prisons in the USA, we conducted a survey of the most restrictive facilities across the country and found that just over half offer sport programs to the young people in their care. Further, we found that girls in prison had less opportunity to play sports than boys. It was encouraging to learn that most of the facilities that offer sports do so with the purpose of promoting positive development which is often found in traditional sport programs and may improve the wellbeing of young people. More research is needed to see if these programs actually result in positive health impacts for young people who are incarcerated.

Delaware Contraceptive Access Now and Contraceptive Initiation Among Medicaid Enrollees, 2015‒2020.

Delaware Contraceptive Access Now was a statewide contraceptive access program implemented in Delaware between 2015 and 2020. We evaluated the association of the program with contraceptive initiation in Delaware's Medicaid program using a difference-in-differences design that compared changes in Delaware to changes in Maryland. Results suggest that program implementation was associated with increased initiation of long-acting reversible methods, particularly among adolescent patients aged 15 to 18 years. We found less-consistent evidence for changes to any contraceptive method. (Am J Public Health. 2022;112(S5):S537-S540. https://doi.org/10.2105/AJPH.2022.306938).

Psychometric characteristics of the health care empowerment questionnaire in a sample of patients with arthritis and rheumatic conditions.

BACKGROUND: Patient empowerment can improve health-related outcomes and is important in chronic conditions, such as arthritis. This study aimed to validate the Health Care Empowerment Questionnaire (HCEQ), a patient-reported experience measure of empowerment, for use with patients with arthritis and other rheumatic diseases. METHODS: The HCEQ measures Patient Information Seeking (or Involvement in Decisions) and Healthcare Interaction Results (or Involvement in Interactions) and asks respondents to answer questions in two ways: whether they feel something happened and its importance to them. Face validity was assessed through qualitative data (n = 8, nominal group technique; n = 55, focus groups). Measure structure was assessed through confirmatory factor analysis (CFA); internal consistency was also assessed (n = 9226). Test-retest reliability was assessed with sub-sample of participants (n = 182). RESULTS: We found adequate face validity of the HCEQ for patients with arthritis. The CFA indicated good fit to the data for the two-factor structure of the HCEQ (RMSEA = 0.075; CFI = 0.987; TLI = 0.978; SRMR = 0.026). Internal consistency was strong (α=0.94 for both subscales). Test-retest reliability was moderate for Patient Information Seeking (ICC=0.67) and good for Healthcare Interaction Results (ICC=0.77). CONCLUSIONS: The HCEQ, with modifications, demonstrated promising psychometric properties within this sample, laying the foundation for further assessment. This work supports the HCEQ as an appropriate instrument for examining experiences with and perceived importance of empowerment in individuals with arthritis and other rheumatic conditions. PATIENT CONTRIBUTION: Patients contributed to the assessment of face validity. As a measure of patient empowerment, the HCEQ's use can enable further participation of patients in health care.

Toward Improved Identification of Parental Substance Misuse: An Examination of Current Practices and Gaps in One US State.

INTRODUCTION: The use of illicit substances, including opioids, is a serious public health issue in the United States. While there are reports of the impact of the ongoing opioid crisis on adults, a new focus has emerged on how parental substance misuse (PSM) affects children. This study explored existing screening and assessment practices and services for children and families affected by PSM across different service sectors in one state. The purpose of the study was to identify opportunities for training, policy development, and practice improvement related to identifying PSM and linking children and parents to services. METHODS: Interviews (n = 15) with professionals from five service sectors (mental health, primary care, schools, community programs, and law enforcement) were used to inform development of a state-wide survey of the same groups (n = 498) to assess current practices, attitudes, knowledge, and training needs related to child screening of PSM. The survey was piloted using cognitive interviewing (n = 9) before it was distributed. RESULTS: Fewer than 20% of survey respondents reported using standardized tools specific to screening PSM. Informal assessment practices predominate, though 60% of respondents saw value in adopting more standardized PSM screening. Attitudes about PSM and screening varied among sectors but interest in training was high. DISCUSSION: Results indicate a need for more systematic PSM screening, cross-sector training and practice discussions, and policies to support early identification of children affected by PSM. Ramifications of these findings and recommendations are discussed.

"Power of Mom": A Mixed Methods Investigation of Mothers' Influence on Women's Contraceptive Attitudes and Behaviors.

OBJECTIVES: Unintended pregnancy is an individual and public health problem with significant social and economic consequences. The literature has established that parents, especially mothers, play an important role in shaping the contraceptive attitudes and behaviors of young women and could therefore affect the likelihood of their daughter experiencing an unintended pregnancy. However, research has yet to fully explore the nuances of how mothers influence their daughters with respect to contraception. METHODS: We conducted a mixed methods study to explore the impact of mothers on women's contraceptive attitudes and behaviors. In-depth interviews were conducted with 86 women of reproductive age to identify potential patterns and explore the nature of mothers' influences. We then analyzed medical and prescription claims for a cohort of 9813 pairs of women (mother-daughter proxies) enrolled in Medicaid, to determine if such patterns of contraceptive use held in a larger sample. RESULTS: In-depth interviews reveal how and why mothers shape women's contraceptive attitudes and behaviors, particularly highlighting the nuances of communication, knowledge, and relationships. The statistical claims data supported such findings on a broader scale. For instance, across several types of contraceptives, including oral, injectable, and long-acting reversible contraceptives (LARCs), young women were significantly more likely to use a particular method if an older woman in the household (mother proxy) also used that method (AOR (95% CI) 1.99 (1.67-2.37), 2.06 (1.58-2.68) and 2.83 (1.64-4.88) respectively). CONCLUSIONS FOR PRACTICE: This study fills a gap in the literature regarding the nuanced ways in which mothers influence women's contraceptive behavior. In turn, it supports the importance of familial context-especially the influence of mothers-in contraception decision-making and suggests that interventions aimed at improving access to and uptake of effective methods of contraception consider this context in their design and implementation.

Health Service Utilization of Children in Delaware Foster Care, 2013-2014.

OBJECTIVE: Children in foster care represent some of the most vulnerable children in the U.S. Their higher prevalence of a range of physical and behavioral health problems can lead to greater health care utilization and higher costs. However, many children in foster care have undiagnosed conditions and unmet needs. The purpose of this study was to provide a description of health services accessed by children in foster care in Delaware. The data serves as a baseline and informs current efforts to improve the health care of children in foster care. We analyzed rates of emergency room visits, behavioral health visits, hospitalizations, and costs of care for children in foster care and made comparisons with other children participating in Medicaid. We also looked at utilization before and after entry into care and assessed rates of appropriate medical screening for children on entering foster care. This study was conducted as part of a larger analysis guided by the Delaware Task Force on the Health of Children in Foster Care with funding appropriated by the Delaware General Assembly. METHODS: Using a unique identification number, we linked Medicaid claims data with demographic information and characteristics associated with foster care from the Delaware Department of Services for Children, Youth and Their Families. We examined diagnoses, patterns of utilization, and costs for children in foster care (n = 1,458) and a comparable cohort of other children in Medicaid (n = 124,667) during fiscal years 2013 and 2014. RESULTS: Compared with other children in Medicaid, children in foster care had similar rates of emergency department utilization, but relatively high rates of outpatient behavioral health visits. Similarly, compared with other children in Medicaid, those in foster care had particularly high rates of psychotropic drug utilization. Entry into foster care was associated with increased utilization of overall health care services, including receipt of well-child care. However, just 31 percent of those new to foster care met the recommended guidelines for a preventive screening in their first 30 days. CONCLUSIONS: Because of the challenges in meeting screening policies for children entering foster care, collaboration among providers, state administrators, and policymakers is essential to guide improvement. Specifically, stakeholders should look for ways to improve the timeliness of preventive screenings and coordination of care. The high rate of behavioral health visits suggests the need to improve integration of behavioral health care into primary care.

A descriptive study of women presenting to an obstetric triage unit with no prenatal care.

OBJECTIVE: To describe women presenting to an obstetric triage unit with no prenatal care (PNC), to identify gaps in care, and to compare care provided to World Health Organization (WHO) standards. METHODS: We reviewed the charts of women who gave birth at Women's Hospital in Winnipeg and were discharged between April 1, 2008, and March 31, 2011, and identified those whose charts were coded with ICD-10 code Z35.3 (inadequate PNC) or who had fewer than 2 PNC visits. Three hundred eighty-two charts were identified, and sociodemographic characteristics, PNC history, investigations, and pregnancy outcomes were recorded. The care provided was compared with WHO guidelines. RESULTS: One hundred nine women presented to the obstetric triage unit with no PNC; 96 (88.1%) were in the third trimester. Only 39 women (35.8%) received subsequent PNC, with care falling short of WHO standards. Gaps in PNC included missing time-sensitive screening tests, mid-stream urine culture, and Chlamydia and gonorrhea testing. The mean maternal age was 26.1 years, and 93 women (85.3%) were multigravidas. More than one half of the women (51.4%) were involved with Child and Family Services, 64.2% smoked, 33.0% drank alcohol, and 32.1% used illicit drugs during pregnancy. Two thirds of the women (66.2%) lived in inner-city Winnipeg. Only 63.0% of neonates showed growth appropriate for gestational age. Two pregnancies ended in stillbirth; there was one neonatal death, and over one third of the births were preterm. CONCLUSION: Most women who present with no PNC do so late in pregnancy, proceed to deliver with little or no additional PNC, and have high rates of adverse outcomes. Thus, efforts to improve PNC must focus on facilitating earlier entry into care. This would also improve compliance with WHO guidelines for continuing care. Treatment protocols could improve gaps in obtaining urine culture and in Chlamydia and gonorrhea testing.

Objectif : Décrire les femmes qui se présentent à une unité de triage obstétricale sans avoir reçu de soins prénataux (SPN), identifier les lacunes en matière de soins et comparer les soins offerts aux normes de l'Organisation mondiale de la santé (OMS). Méthodes : Nous avons analysé les dossiers des femmes ayant accouché au Women's Hospital de Winnipeg et y ayant obtenu leur congé entre le 1er avril 2008 et le 31 mars 2011, ce qui nous a permis d'identifier les femmes qui avaient obtenu moins de deux consultations SPN ou dont les dossiers s'étaient mérités le code ICD-10 Z35.3 (SPN inadéquats). Trois cent quatre-vingt-deux dossiers ont été identifiés et les caractéristiques sociodémographiques, les antécédents en matière de SPN, les explorations et les issues de grossesse ont été consignés. Les soins offerts ont été comparés aux lignes directrices de l'OMS. Résultats : Cent neuf femmes se sont présentées à l'unité de triage obstétricale sans avoir reçu de SPN; 96 (88,1 %) d'entre elles en étaient rendues au troisième trimestre. Seules 39 femmes (35,8 %) ont par la suite reçu des SPN et ceux-ci restaient en deçà des normes de l'OMS. Parmi les lacunes en matière de SPN, on trouvait l'absence de tests de dépistage dont la tenue à certains moments précis de la grossesse s'avère indiquée, de la mise en culture d'un échantillon permictionnel et de la mise en œuvre d'un dépistage de la chlamydiose et de la gonorrhée. L'âge maternel moyen était de 26,1 ans et 93 de ces femmes (85,3 %) étaient multigestes. Plus de la moitié de ces femmes (51,4 %) étaient suivies par les Services à l'enfant et à la famille, 64,2 % fumaient, 33,0 % consommaient de l'alcool et 32,1 % consommaient des drogues illicites pendant la grossesse. Deux tiers de ces femmes (66,2 %) habitaient les quartiers centraux de la ville de Winnipeg. Seuls 63,0 % des nouveau-nés présentaient une croissance correspondant bien à l'âge gestationnel. Deux grossesses se sont soldées en une mortinaissance; un décès néonatal a été constaté et plus du tiers des accouchements ont été prématurés. Conclusion : La plupart des femmes qui se présentent sans avoir reçu de SPN le font tard au cours de la grossesse, en viennent à accoucher en n'ayant reçu que peu ou pas de SPN supplémentaires et connaissent des taux élevés d'issues indésirables. Ainsi, les efforts visant l'amélioration des SPN se doivent de chercher à permettre à ces femmes d'obtenir plus tôt accès à de tels soins. Un tel objectif entraînerait également une meilleure harmonisation avec les lignes directrices de l'OMS pour ce qui est des soins continus. La mise en œuvre de protocoles de traitement pourrait permettre de combler les lacunes en ce qui concerne la mise en culture de l'urine et le dépistage de la chlamydiose et de la gonorrhée.

Shifting public health practice to advance health equity: recommendations from experts and community leaders.

CONTEXT: While the evidence base regarding the social determinants of health and their relationship to health inequities grows, the field of public health is challenged to translate this knowledge into practice changes that advance health equity. OBJECTIVE: Drawing on the knowledge, beliefs, and experiences of public health experts and community leaders working to advance health equity, our objective was to develop and disseminate recommendations for changing public health practice to better address this problem. DESIGN: We conducted semistructured, qualitative telephone interviews (n = 25) with key informants. Interviews were recorded and transcribed, and data were coded and analyzed using both inductive and deductive methods. Member checks were used to enhance quality. SETTING AND PARTICIPANTS: A purposeful sample of key informants was selected from content experts and community leaders involved with the development of the Unnatural Causes public impact campaign. Participants represented state and local health departments, community-based organizations, national research/advocacy organizations, and academic institutions across the country. RESULTS: Participants distinguished between social determinants of health and their structural precursors in social and political institutions. They believed that the field of public health has an obligation to address health inequities and shifts in practice are needed that focus more attention on societal factors that underlie such inequities. According to participants, specific practice changes are difficult to identify because actions should be community specific and community driven. Recommended approaches that may be adapted to community-based needs and assets include building nontraditional partnerships, engaging in political advocacy, promoting community leadership, collecting better data on social conditions and institutional factors, and enhancing communication for health equity. CONCLUSIONS: Recommended shifts in practice may be facilitated by revisiting our understanding of the 3 core functions of public health-assessment, assurance, and policy development.

"We Are All There to Make Sure the Baby Comes Out Healthy":: A Qualitative Study of Doulas' and Licensed Providers' Views on Doula Care.

Policymakers are exploring ways to expand access to doula care to address persistent inequities in maternal and infant health across the United States. Doulas are non-medical professionals who provide physical, emotional, and informational support to birthing people before, during and after childbirth. Growing evidence supports the role of doulas in improved birth outcomes. Delaware is among several states moving towards Medicaid reimbursement for doula care to serve those most at risk. Objective: To gain an in-depth understanding of key stakeholders' knowledge, attitudes, beliefs and experiences regarding doula training and certification, relationships among providers, and other potential needs related to infrastructure to identify areas of agreement and inform policy change in the state of Delaware. Methods: We conducted focus groups with 11 doulas and key-informant interviews with 12 licensed providers practicing in Delaware, including six nurses, four physicians and two certified nurse midwives. Qualitative data was collected via Zoom (video conferencing) between September 2022 and April 2023. Results: Analysis revealed themes related to training, credentials and competencies of doulas, including cultural competence; logistical, administrative, and financial considerations for policy and practice change; and the whole care team-relationships between doulas and medical partners, and opportunities for growth. Conclusions: Doulas and licensed providers agree on key elements of doula training, the value of certification, the need for financial support, and the importance of relationship-building across the care team. Policy implications: Areas of agreement among stakeholders provide a foundation for state leaders to move forward to ensure the delivery of the most accessible, high quality, and culturally competent doula care for birthing people in Delaware.

LLIN Evaluation in Uganda Project (LLINEUP)-effects of a vector control trial on Plasmodium infection prevalence and genotypic markers of insecticide resistance in Anopheles vectors from 48 districts of Uganda.

Pyrethroid bednets treated with the synergist piperonyl butoxide (PBO) offer the possibility of improved vector control in mosquito populations with metabolic resistance. In 2017-2019, we conducted a large-scale, cluster-randomised trial (LLINEUP) to evaluate long-lasting insecticidal nets (LLINs) treated with a pyrethroid insecticide plus PBO (PBO LLINs), as compared to conventional, pyrethroid-only LLINs across 104 health sub-districts (HSDs) in Uganda. In LLINEUP, and similar trials in Tanzania, PBO LLINs were found to provide greater protection against malaria than conventional LLINs, reducing parasitaemia and vector density. In the LLINEUP trial, we conducted cross-sectional household entomological surveys at baseline and then every 6 months for two years, which we use here to investigate longitudinal changes in mosquito infection rate and genetic markers of resistance. Overall, 5395 female Anopheles mosquitoes were collected from 5046 households. The proportion of mosquitoes infected (PCR-positive) with Plasmodium falciparum did not change significantly over time, while infection with non-falciparum malaria decreased in An. gambiae s.s., but not An. funestus. The frequency of genetic markers associated with pyrethroid resistance increased significantly over time, but the rate of change was not different between the two LLIN types. The knock-down resistance (kdr) mutation Vgsc-995S declined over time as Vgsc-995F, the alternative resistance mutation at this codon, increased. Vgsc-995F appears to be spreading into Uganda. Distribution of LLINs in Uganda was previously found to be associated with reductions in parasite prevalence and vector density, but here we show that the proportion of infective mosquitoes remained stable across both PBO and non-PBO LLINs, suggesting that the potential for transmission persisted. The increased frequency of markers of pyrethroid resistance indicates that LLIN distribution favoured the evolution of resistance within local vectors and highlights the potential benefits of resistance management strategies.Trial registration: This study is registered with ISRCTN, ISRCTN17516395. Registered 14 February 2017, http://www.isrctn.com/ISRCTN17516395 .

LLIN Evaluation in Uganda Project (LLINEUP) - Plasmodium infection prevalence and genotypic markers of insecticide resistance in Anopheles vectors from 48 districts of Uganda.

Background: In 2017-2019, we conducted a large-scale, cluster-randomised trial (LLINEUP) to evaluate long-lasting insecticidal nets (LLINs) treated with a pyrethroid insecticide plus the synergist piperonyl butoxide (PBO LLINs), as compared to conventional, pyrethroid-only LLINs across 104 health sub-districts (HSDs) in Uganda. In LLINEUP, and similar trials in Tanzania, PBO LLINs were found to provide greater protection against malaria than conventional LLINs, reducing parasitaemia and vector density. In the LLINEUP trial, cross-sectional entomological surveys were carried out at baseline and then every 6 months for two years. In each survey, ten households per HSD were randomly selected for indoor household entomological collections. Results: Overall, 5395 female Anopheles mosquitoes were collected from 5046 households. The proportion of mosquitoes infected with Plasmodium falciparum did not change significantly over time, while infection with non-falciparum malaria decreased in An. gambiae s.s, but not An. funestus. The frequency of genetic markers associated with pyrethroid resistance increased significantly over time, but the rate of change was not different between the two LLIN types. The knock-down resistance (kdr) mutation Vgsc-995S declined over time as Vgsc-995F, the alternative resistance mutation at this codon, increased. Vgsc-995F appears to be spreading into Uganda. Conclusions: Distribution of LLINs in Uganda was associated with reductions in parasite prevalence and vector density, but the proportion of infective mosquitoes remained stable, suggesting that the potential for transmission persisted. The increased frequency of markers of pyrethroid resistance indicates that LLIN distribution favoured the evolution of resistance within local vectors and highlights the potential benefits of resistance management strategies.Trial registration:: This study is registered with ISRCTN, ISRCTN17516395. Registered 14 February 2017, http://www.isrctn.com/ISRCTN17516395.

Patient Empowerment Among Adults With Arthritis: The Case for Emotional Support.

OBJECTIVE: This study aimed to identify differences in patient empowerment based on biopsychosocial patient-reported measures, the magnitude of those differences, and which measures best explain differences in patient empowerment. METHODS: This was a cross-sectional observational study of 6918 adults with arthritis in the US. Data were collected from March 2019 to March 2020 through the Arthritis Foundation Live Yes! INSIGHTS program. Patient empowerment, measured by the Health Care Empowerment Questionnaire, included 2 scales: Patient Information Seeking and Healthcare Interaction Results. Patient-reported outcomes were measured using the Patient Reported Outcomes Measurement Information System (PROMIS)-29 and PROMIS emotional support scale. ANOVA assessed differences between groups, and Spearman rank correlation assessed correlations between variables. Hierarchical regression analysis determined the contributions of sociodemographic characteristics, arthritis type, and patient-reported health measures in explaining patient empowerment (α = 0.05). RESULTS: Empowerment was lower among those who were male, older, less educated, or who had lower income, osteoarthritis, less emotional support, or better physical function, although the effect was small-to-negligible for most of these variables in the final regression models. Empowerment did not differ by race/ethnicity in unadjusted or adjusted analysis. In final regression models, emotional support contributed the most to explaining patient empowerment. CONCLUSION: Emotional support is important for patient empowerment. This suggests that programs that seek to improve patient empowerment should target and measure effects on emotional support.

Barriers and facilitators to opioid agonist therapy in rural and remote communities in Canada: an integrative review.

BACKGROUND: People living in rural and remote communities in Canada are often disproportionately impacted by opioid use disorder. When compared to urban centres, rural and remote populations face additional barriers to treatment, including geographical distance as well as chronic shortages of health care professionals. This integrative review of the literature was conducted to explore the facilitators and barriers of OAT in rural and remote Canadian communities. METHODS: A search of the literature identified relevant studies published between 2001 and 2021. RESULTS: The search strategy yielded 26 scholarly peer-reviewed publications, which explored specific barriers and facilitators to rural and remote OAT in Canada, along with two reports and one fact sheet from the grey literature. Most of the scholarly articles were descriptive studies (n = 14) or commentaries (n = 9); there were only three intervention studies. Facilitators and barriers to OAT programs were organized into six themes: intrapersonal/patient factors, social/non-medical program factors, family/social context factors (including community factors), infrastructure/environmental factors, health care provider factors, and system/policy factors. CONCLUSIONS: Although themes in the literature resembled the social-ecological framework, most of the studies focused on the patient-provider dyad. Two of the most compelling studies focused on community factors that positively impacted OAT success and highlighted a holistic approach to care, nested in a community-based holistic model. Further research is required to foster OAT programs in rural and remote communities.

Improving health across sectors: Best practices for the implementation of health in all policies approaches.

Health is influenced by a broad range of factors beyond the typical remit of public health. It is therefore increasingly recognized that multiple sectors need to be engaged to improve population health. Health in All Policies (HiAP) is an approach to systematically consider health across policies and programs. This study assessed best practices and gaps in HiAP operationalization to inform practitioners aiming to incorporate HiAP in their work. We used Delaware as a model state to examine operationalization factors in a jurisdiction planning to implement HiAP. Methods included document review, key informant interviews, focus groups, and a questionnaire conducted in Delaware and virtually. Thematic analysis was used to analyze qualitative data to provide information on best practices and gaps in existing HiAP programs and context in Delaware. Descriptive statistics were used to examine collaboration in Delaware and to support or refute qualitative findings. We identified two gaps that can hinder HiAP implementation: 1) HiAP practitioners do not adequately use strategic communications to increase buy-in across sectors; 2) practitioners do not fully recognize the importance of being adaptable throughout HiAP implementation, which hinders sustainability. Qualitative findings from Delaware offer insight to these gaps and opportunities to address them. Refining the essential elements of HiAP to add: 1) strategic communications across sectors and 2) flexibility throughout HiAP implementation may point the way to more successful adoption of HiAP approaches across jurisdictions. This research demonstrated the importance of examining local perspectives on HiAP before implementation based on a jurisdiction's context.

What 2020 Taught Us about the Politics and Teaching of Public Health.

The COVID-19 pandemic has illuminated the critical need to make greater investments in public health and build the capacity of the public health workforce. Among the professional competencies needed to address the ongoing morbidity and mortality associated with COVID-19, as well as other current and future public health challenges, is the ability to effectively engage in the political process. While we acknowledge that public health institutions and workers are under-resourced and are grateful for their tireless efforts to control the pandemic, we argue that their efforts have been severely hampered by a notable absence from politics. We argue that our ability to protect and promote public health has been further challenged by divisive political rhetoric from the former presidential administration, which has amplified a culture of self-interest and individualism. Such values are counter to public health and threaten our ability to address the disproportionate impacts of COVID-19 on low-income communities and communities of color, along with the myriad of health inequities experienced by marginalized communities in the US. We assert that public health professionals must be better equipped and supported in their efforts to challenge powerful majorities that have generated such unhealthy and unequal social and environmental conditions. Policy change related to social determinants of health should be an integral component of our intervention strategies and political advocacy should be considered a core competency for training future public health professionals. The field needs professionals comfortable and adept at working within the political sphere; students are eager for skills that allow them to translate their passion for social justice in health; and the persistent and pervasive health inequities experienced by marginalized communities demand such action.

Difficult binds: A systematic review of facilitators and barriers to treatment among mothers with substance use disorders.

BACKGROUND: The United States and Canada have observed sharp increases in substance use disorder among women of child-bearing or child-rearing age. Substance use disorder can have deleterious effects on children, families, and communities. Many evidence-based treatments exist, but engaging mothers in treatment is difficult. No recent review is available to help systems and providers understand the facilitators of and barriers to treatment for mothers. OBJECTIVE: To systematically identify facilitators and barriers to substance use and mental health treatment for mothers with substance use disorder who are pregnant or parenting young children in the United States and Canada. METHODS: We systematically searched the literature using five online databases and performed a gray literature search. We included studies published in the past two decades focused on parent or provider perspectives. RESULTS: Our search identified 23 high-quality papers. The majority of papers qualitatively examined the perspectives of treatment-seeking pregnant women and mothers diverse in race/ethnicity, region, and treatment settings. Our synthesis of findings revealed the compelling and complex centrality of motherhood, which served as both a facilitator and barrier. Motherhood often interacted with relational (e.g., perceiving stigma vs. support from providers, family, friends, partners) and structural (e.g., time commitments, childcare) factors to both hinder and help engagement in treatment. CONCLUSIONS: Our findings can help policy-makers and practitioners make tangible improvements to the financing and delivery of substance use treatment for mothers. Our review points to specific areas for future research, including an examination of the relationships between various structural factors and treatment outcomes.

Postpartum contraception method type and risk of a short interpregnancy interval in a state Medicaid population.

OBJECTIVE: To evaluate the likelihood of a short interpregnancy interval (IPI) resulting in a birth among women covered by Medicaid, as a function of postpartum contraceptive method type. STUDY DESIGN: We used Medicaid claims and eligibility data to identify women (aged 15-44) who had a Medicaid-financed birth in Delaware in the years 2012-2014 (n = 10,328). Claims were analyzed to determine postpartum contraceptive type within 60 days of the index birth, and linked birth certificates were used to determine the incidence and timing of a subsequent birth through 2018 (regardless of payer). We used logistic regression to analyze the likelihood of having a short IPI following the index birth as a function of postpartum contraceptive type, controlling for preterm births, parity, having a postpartum checkup, and maternal characteristics including age, race, education, and marital status. RESULTS: Compared to patients receiving postpartum long-acting reversible contraceptive methods (LARC), patients with no contraceptive claims had nearly 5 times higher odds (odds ratio [OR] = 4.98, confidence interval [CI] = 3.05-8.13) and those with claims for moderately effective methods (injectable, pill, patch, or ring) had 3.5 times higher odds (OR = 3.51, CI = 2.13-5.77) of a subsequent birth following a short IPI. CONCLUSIONS: In a state population of Medicaid-enrolled women, women with claims for postpartum LARC had substantially lower risk of a short IPI resulting in a birth. IMPLICATIONS: Women who received LARC within 60 days postpartum are less likely to experience a short interpregnancy interval resulting in a birth. The evidence suggests that recent state policy changes that make postpartum LARC more accessible to those that desire it will be an effective strategy in helping patients obtain desired birth intervals.

Stakeholder Development of an Online Program to Track Arthritis-Related Patient-Reported Outcomes Longitudinally: Live Yes! INSIGHTS.

OBJECTIVE: Patient-reported outcome measures (PROMs) are increasingly used in clinical settings but may not provide benefits to patients outside of health encounters. The Arthritis Foundation's Live Yes! Network provides an opportunity for PROM use by individuals and the network that assists individuals with managing their arthritis between encounters. Our objective was to develop a patient-reported outcomes platform for the network, Live Yes! INSIGHTS, using mixed methods and extensive stakeholder input. METHODS: A mixed methods longitudinal transformation design was used, starting with semistructured interviews to specify the main priorities of the program, literature review to identify potential PROMs, modified Delphi and nominal group technique to select final PROMs, and focus groups to guide program implementation, messaging, and use of results. We gathered input from 93 participants, including from individuals living with arthritis (74% of participants), caregivers, providers, researchers, and measurement experts. RESULTS: Our mixed methods study resulted in the selection of Patient-Reported Outcomes Measurement Information System (PROMIS)-29, PROMIS Emotional Support Short Form v2.0, and the Health Care Empowerment Questionnaire, to be deployed through a Qualtrics platform. Triangulation of data resulted in identification of potential risks and benefits, including confidentiality, ability to personally track and share data, and an opportunity to contribute to research. CONCLUSION: An accessible measurement system backed by psychometrically strong PROMs, created with robust stakeholder engagement, and linked to a national patient network sets the stage for individuals with arthritis to better monitor and improve health outcomes both outside and inside health care settings and for the network to customize programming to meet needs.