Promoting Policy Development through Community Participatory Approaches to Health Promotion: The Philadelphia Ujima Experience.

BACKGROUND: The Philadelphia Ujima Coalition for a Healthier Community (Philadelphia Ujima) promotes health improvement of girls, women, and their families using a gender framework and community-based participatory research approach to addressing gender-based disparities. Institutional policies developed through community-based participatory research approaches are integral to sustaining gender-integrated health-promotion programs and necessary for reducing gender health inequities. This paper describes the results of a policy analysis of the Philadelphia Ujima coalition partner sites and highlights two case studies. METHODS: The policy analysis used a document review and key informant interview transcripts to explore 1) processes that community, faith, and academic organizations engaged in a community participatory process used to develop policies or institutional changes, 2) types of policy changes developed, and 3) initial outcomes and impact of the policy changes on the target population. RESULTS: Fifteen policies were developed as a result of the funding from the U.S. Department of Health and Human Services Office on Women's Health. Policy changes included 1) healthy food options guidance, 2) leadership training on sexual and relationship violence, and 3) curricula and programming inclusion and expansion of a sex and gender focus in high school and medical school. CONCLUSIONS: Organizational practice changes and policies can be activated through individual-level interventions using a community participatory approach. This approach empowers communities to play an integral role in creating health-promoting policies.

Efficacy of initial antiretroviral therapy for HIV-1 infection in adults: a systematic review and meta-analysis of 114 studies with up to 144 weeks' follow-up.

BACKGROUND: A comprehensive assessment of initial HIV-1 treatment success may inform study design and treatment guidelines. METHODS: Group-based, systematic review and meta-analysis of initial antiretroviral therapy studies, in adults, of ≥ 48 weeks duration, reported through December 31, 2012. Size-weighted, intention-to-treat efficacy was calculated. Parameters of study design/eligibility, participant and treatment characteristics were abstracted. Multivariable, random effects, linear regression models with backwards, stepwise selection were then used to identify variables associated with efficacy. OUTCOME MEASURES: Antiviral efficacy (undetectable plasma viral load) and premature cessation of therapy. RESULTS: 114 studies were included (216 treatment groups; 40,124 participants; mean CD4 count 248 cells/µL [SD 81]; mean HIV-1 plasma viral load log10 4.9 [SD 0.2]). Mean efficacy across all groups was 60% (SD 16) over a mean 82 weeks' follow-up (SD 38). Efficacy declined over time: 66% (SD 16) at 48 weeks, 60% (SD 16) at 96 weeks, 52% (SD 18) at 144 weeks. The most common reason for treatment cessation was participant decision (11%, SD 6.6). Efficacy was higher with 'Preferred' than 'Alternative' regimens (as defined by 2013 United States antiretroviral guidelines): 75% vs. 65%, respectively, difference 10%; 95%CI 7.6 to 15.4; p<0.001. In 98 groups (45%) reporting efficacy stratified by pre-treatment viral load (< or ≥100,000 copies/mL), efficacy was greater for the lower stratum (70% vs. 62%, respectively, difference 8.4%; 95%CI 6.0 to 10.9; p<0.001). This difference persisted within 'Preferred' regimens. Greatest efficacy was associated with use of tenofovir-emtricitabine (vs. other nucleoside analogue backbones) and integrase strand transfer inhibitors (vs. other third drug classes). CONCLUSION: Initial antiretroviral treatments for HIV-1 to date appear to have suboptimal long-term efficacy, but are more effective when commenced at plasma viral loads <100,000 copies/mL. Rising viral load should be considered an indication for starting treatment. Integrase inhibitors offer a treatment advantage (vs. other third drug classes).

Beyond bioethics: reckoning with the public health paradigm.

In the wake of scandal over troubling research abuses, the 1970s witnessed the birth of a new system of ethical oversight. The bioethics framework, with its emphasis on autonomy, assumed a commanding role in debates regarding how to weigh the needs of society against the rights of individuals. Yet the history of resistance to oversight underscores that some domains of science hewed to a different paradigm of accountability--one that elevated the common good over individual rights. Federal officials have now proposed to dramatically limit the reach of ethical oversight. The Institute of Medicine has called for a rollback of the federal privacy rule. The changing emphasis makes it imperative to grapple with the history of the public interest paradigm.

First, do no harm. HHS' National Quality Strategy uses broad approach to communicate expectations to providers.

HHS laid out the framework for its quality-improvement priorities, and providers greeted it with praise. "This is very much in keeping with what we are trying to do for our community as an integrated health system. It helps us partner with patients so there is shared responsibility, and there is also a focus on wellness, which we know is critical to the future of healthcare and controlling costs," says Dr. Nick Turkal, left, of Aurora Health Care.

Simplicity sells: Making smoking cessation easier.

Toll-free telephone quitlines are successful alternatives to direct clinician contact. In 2004, the U.S. Department of Health and Human Services created a national quitline number, 1-800-QUIT-NOW. This enabled states without quitlines to establish them, giving free access to cessation services to every smoker in the U.S. It also created a new mechanism for national quitline marketing, employing simplified and streamlined approaches.

Conforming to HIPAA regulations and compilation of research data.

PURPOSE: A set of deidentified patient data compliant with the Health Information Portability and Accountability Act (HIPAA) was compiled, the data lost as a function of unique data elements (UDEs) were measured, and the deidentified data were tested for potential for reidentification. METHODS: After approval by the institutional review board of an integrated health system, a limited-data set was created by querying the health system's pharmacy, administrative, and financial files for patients discharged between January 1 and December 31, 2000. Using the HIPAA "safe-harbor" method, this limited-data set was converted into a deidentified-data table for future statistical analysis, and UDEs in both data sets were identified and quantified. Unique combinations of commonly available data were also identified. RESULTS: The limited-data set, representing 4,738 patient discharges, contained 810,456 UDEs in 322,657 records organized into four data tables (demographics, diagnoses, medication orders, and laboratory test results). The deidentified-data table, representing 4,722 discharges, contained 562,171 UDEs in 128 data-type columns in a single data table. About 31% of the data volume was lost. Much of the information lost was of the type that is of special interest to researchers (e.g., time between episodes of care, ages of >89 years). CONCLUSION: A study suggested that deidentified patient data with a reasonable degree of protection against reidentification were less complete than may be necessary for good research.