Adolescent Healthcare Access: A Qualitative Study of Provider Perspectives.

INTRODUCTION: Adolescent access to quality healthcare is key to prevention and early intervention for health risk behaviors. This paper provides a healthcare provider perspective on barriers and facilitators to youth accessing care. METHODS: Five focus groups were conducted from November to December 2020 with providers from a variety of healthcare settings. Participants were asked to describe their respective adolescent patient populations, adolescent-specific health concerns, and organizational accommodations specific for youth services. Transcripts were analyzed using Inductive Thematic Analysis and themes were grouped using a social-ecological framework. RESULTS: At an individual level, providers noted that an adolescent's knowledge and ability to navigate services varied greatly across settings. Providers identified provider trust and parent/guardian support as key interpersonal factors that support adolescents' access to services. Organizational factors included bureaucratic barriers and the clinic's reputation among youth. Community factors centered on mistrust within healthcare systems and stigmatization of seeking certain types of services. Participants also described how state-level policies influence parent/guardian consent requirements, which can limit adolescents' access to care. CONCLUSION: Adolescent access to and utilization of healthcare in the United States is a complex problem requiring systems-level change. Healthcare organizations and providers have the opportunity and capacity to positively influence adolescents' healthcare access and experiences, however a lack of standardized, clinic-level priorities and guidelines can limit adolescent-centered care.

Insights From a Community-Based Strategy to Assess Tobacco and Vape Shop Retailers' Implementation of Tobacco 21 Law in El Paso, Texas.

In 2019, the United States Congress passed Tobacco 21 (T21) legislation that raised the minimum legal sales age for tobacco products from 18 to 21. However, although the federal legislation superseded weaker state laws that were already in place in some states, including Texas, local guidance for retailers was inconsistent. Given that retailers are ultimately responsible for policy implementation, the American Heart Association (AHA) initiated a process of assessing retailers knowledge and perceptions of the law through a survey targeting all tobacco retailers and accompanying ethnography of a subset of vape shops in El Paso, Texas. The process yielded lessons learned for assessment of community-based policy implementation including key considerations for personnel and process that are applicable to other community-based assessment processes. While AHA considered an in-person approach ideal, having an alternate online response option was necessary. In addition, a focused approach and in-depth understanding of the purpose was key to responsiveness of the retailers.

Development of Youth-Centered Health Messaging Posters for High School-Based Health Clinics in Hawaii.

BACKGROUND: Youth may be reluctant to seek health care from school health providers due to feeling embarrassed or stigmatized in the health office environment or worried about their confidentiality. The purpose of this project was to create a set of youth-centered health posters that promote youth engagement with nursing staff and to standardize health messaging across high schools in Hawaii school-based clinics. METHODS: Two community advisory boards, 1 composed of 10 youth stakeholders (mean age 17 years) and the other of 7 adult stakeholders, informed poster development utilizing web-based discussion groups. The discussions were transcribed, and additional data was collected using field notes and anonymous digital messages. Adult advisory board members also provided feedback on suggested poster text through an online survey. RESULTS: Youth and adult advisory board participants identified 4 key health concerns facing youth: confidentiality, sexual health, relationships, and mental health. Based on input from the 2 advisory boards, 4 posters were developed, each centered on 1 key health issue. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: School-based posters can convey important messages to help youth understand their health care rights and responsibilities, as well as identify important issues open for discussion with nurses. CONCLUSION: Posters are an underutilized tool for school health providers to create welcoming, inclusive health care environments and facilitate health-related conversations with youth. This paper describes participant feedback about the characteristics of a memorable poster and briefly outlines current knowledge and recommendations for school health providers regarding each of the 4 health issues.

'We are suffering. Nothing is changing.' Black mother's experiences, communication, and support in the neonatal intensive care unit in the United States: A Qualitative Study.

OBJECTIVES: Black mothers experience markedly disproportionate maternal morbidity and mortality in the United States, with racism often cited as the root cause manifesting through several pathways. The study examined Black mothers' perceived provider communication, support needs, and overall experiences in the neonatal intensive care unit (NICU). DESIGN: This study used grounded theory embedded in the Black feminist theoretical (BFT) framework to generate new ideas grounded in the data. Data was collected through semi-structured interviews using videoconferencing, with questions related to the mother's overall NICU experiences, communication within the NICU, and perceived support needs. Data were analyzed using thematic analysis. RESULTS: Twelve mothers participated in the study; most were married (n = 10), had a cesarean birth, had a previous pregnancy complication (e.g., diabetes, hypertension), had attained a graduate degree or more (n = 9), earned an annual household income of $75,000 or more, and were between 35-44 years of age (n = 7). Three broad domains with several accompanying themes and sub-themes were identified, explicating the mother's experiences in the NICU. Specifically, factors influencing NICU hospitalization for mothers included maternal care/nursing experiences, interactions in the NICU, and the perceived support need that might attenuate negative care and birthing experiences. . CONCLUSION: The study adds to the growing literature championing Black maternal health equity and multilevel quality improvement strategies to foster equitable maternal health. Our study reinforces the need for racially congruent interventions and policy reformations to protect Black birthing people regardless of socioeconomic factors and social class using life course, holistic approaches, and intersectionality mindset. Importantly, using the BFT, this study calls for culturally sensitive research to capture the nuances associated with the multiplicity of experiences of Black people.

The Development of a Systems-Level Approach to Address Adolescent Access to Health Care: A Novel Confidentiality Policy Intervention.

Most evidence-based interventions in adolescent sexual and reproductive health and mental health remain largely aimed at individual-level outcomes and do not conceptualize adolescent health within a social-ecological model. Interventions to affect policy, systems, and environmental change offer potential for sustained population impact. The current initiative used an innovation framework to develop a novel systems-level approach to address adolescent access to health care. The Framework for Public Health Innovation provided an approach to develop a novel intervention. Confident Teen is a systems-level intervention that creates the opportunity, through organizational policy change, to increase adolescents' access to confidential sexual and reproductive health services through organizational policies. Gaps in adolescents' access to health care services allowed for a systems-level approach to be designed through an adolescent pregnancy prevention innovation initiative. Confidentiality is a right and critical component to their health care; therefore, a policy and conversation between provider and patient is a prioritized component of the novel intervention.

Addressing Evaluation Barriers with Early Innovation Development for Adolescent-Focused Sexual and Reproductive Health Interventions.

Most evidence-based teen pregnancy prevention programs focus on individual-level sexual health outcomes (e.g., STIs, pregnancy, teen births). To expand program and intervention approaches within teen pregnancy prevention (TPP), the Department of Health and Human Services funded two grantees, Innovative Teen Pregnancy Prevention Programs (iTP3) and Innovation Next (IN) to support and enable early innovation to advance adolescent health and prevent teen pregnancy. The pipeline to support and enable innovation in adolescent health is complex, resulting in barriers and challenges to research and evaluation of novel programs. This paper presents some of the barriers encountered by the grantees. Data for this paper was collected from key personnel and secondary data sources. Focus group participants included seven representatives (n = 7) across the two organizations. Focus group questions assessed barriers related to innovative intervention development and evaluation. Key findings include four barriers to evaluation when fostering innovative adolescent-focused pregnancy prevention interventions. These included (a) funding constraints on evaluation activities, (b) innovation readiness for rigorous testing, (c) evaluation knowledge and expertise on innovation-development teams, and (d) challenges with evaluation requirements. Novel and promising system- and technology-focused interventions with the potential to impact TPP require alternative tools and approaches for evaluation. This would allow research to focus on how systems-level change mechanisms (i.e., policy, access to care) impact sexual risk behaviors and better understand ecological and social determinants of health for the priority population. The advancement of approaches to impact adolescent health identifies the need to expand the focus of evidence-based interventions beyond the adolescent themselves and understand approaches that impact external contexts and environments related to reducing sexual and reproductive health (SRH) risk-taking.

Continuity of maternal and infant care through integrated health service delivery networks in Latin America: a scoping review.

Latin America has experienced substantial development over the last three decades; however, development has been uneven with persistent inequalities, especially in the areas of maternal and child health. Since the early 1990s, most Latin American health-care systems have undergone a series of reforms to improve access to services, with the most recent being the implementation of integrated health service delivery networks (IHSDNs). This model posits that patients will receive better continuity of care and higher-quality health services and avoid duplicated efforts. While decreased maternal and infant mortality rates have been observed in the region since IHSDN implementation, there is limited evidence on this model's implications for maternal and infant care. The purpose of this study is to explore how IHSDNs affect access to and continuity of maternal and infant care in Latin America, according to the peer-reviewed literature. A scoping review was conducted systematically to identify peer-reviewed articles published since 2007 on studies that took place in Latin America, include IHSDNs, focus on the antenatal and/or postnatal period, include women and/or infants under 2 years of age and are written in English, Spanish or Portuguese. Seven studies (n = 7) met the inclusion criteria for this review. Barriers identified were related to person-centred care (n = 5) and logistical challenges (n = 5). The most cited facilitator encompassed social support for women when accessing care (n = 3). Potential solutions to improve care access included an improvement in the network structure and a greater focus on care provision, rather than regulations and compliance. Findings from this study suggest that the IHSDN model has the potential to improve care for women during pregnancy and post-birth if the model is implemented to its full extent. However, implementation of the model in Latin America is still weak, creating barriers for women when seeking care, particularly for disparate populations and those residing in rural areas.

What Black Mothers with Preterm Infants Want for Their Mental Health Care: A Qualitative Study.

Title: "I think that some culturally sensitive mental health information could have been provided": What Black mothers with preterm infants want for their mental health care: A qualitative study. Background: In the United States, preterm birth (PTB) rates in Black women are 50% higher than in non-Hispanic White and Hispanic mothers. Existing discriminatory sociohistorical and contemporary health care practices have been linked to the alarmingly higher rates of PTB among Black families. While it is well-known that PTB is associated with increased mental health (MH) problems, Black women experience elevated MH burdens due to inequities along the care continuum in the neonatal intensive care unit (NICU). Consequently, culturally responsive MH care holds promises to achieve maternal MH equity. This study aimed to explore the available MH services and resources in the NICU for Black mothers with preterm infants. We also sought to discover potential recommendations and strategies for MH programs through a cultural lens. Materials and Methods: Semistructured interviews were conducted with Black mothers with preterm infants using a Grounded Theory approach embedded in the Black feminist theory. Results: Eleven mothers who gave birth to a preterm infant between 2008 and 2021 participated in this study. Eight women reported not receiving MH services or resources in the NICU. Interestingly, of the three mothers who received MH referrals/services, two did so one-year postbirth and did not utilize the services. Three main themes emerged: stress and the NICU experience, coping mechanisms, and culturally appropriate MH care with diverse providers are needed. Overall, our finds suggest that MH care is not prioritized in the NICU. Conclusion: Black mothers with preterm infants encounter numerous negative and stressful experiences that exacerbate their MH during and beyond the NICU. However, MH services in the NICU and follow-up services are scarce. Mothers in this study endorsed creating culturally appropriate MH programs that addresses their unique intersections.

Assessment of Action Plans as a Guide for Equity-Focused Coalition Work.

Collaborative capacity within coalitions is required to promote healthy communities and create systemic change. The purpose of this study was to evaluate the quality of three Tobacco Prevention and Control Coalitions' action plans for their likely ability to address health equity through tobacco cessation efforts. To do this, the Butterfoss State Plan Index was adapted for relevance to community-oriented coalitions, with a focus on health disparities and tobacco control. This study compares three tobacco control coalitions in Texas to quantify their efforts on addressing health disparities through a standardized measurement process. The results of this assessment indicate that there are gaps in existing coalition assessment tools, and action plan norms and requirements, specifically as it pertains to addressing health disparities in a systematic way. Through a systematic analysis of coalition action plans and supporting documents, it is clear that there is a need for more standard inclusion of disparities-focused work within action plans. Community health researchers, coalition members, and coalition funders should consider action plans to be living, iterative documents that are subject to adjustments. Systems-thinking perspective should be used to develop action plans adapted to environmental, community, policy, and other changes. Lessons learned from this study can provide an example of how to incorporate strategies for reducing health disparities within coalition action planning.

Understanding the Domains of Experiences of Black Mothers with Preterm Infants in the United States: A Systematic Literature Review.

OBJECTIVE: To report the domains of Black mothers' experiences with preterm infants in the neonatal intensive care unit (NICU) and to determine the frameworks used. METHODS: A systematic review of the literature using the PRISMA guideline was performed. An electronic database search of published literature between 2000 and 2022 was conducted based on predetermined search terms and parameters. RESULTS: Twenty-seven articles met the inclusion and exclusion criteria. Eleven articles focused on feeding practices, ten reported on nursing/maternal care experiences, five reported mental health/social support, and only one focused on mother-infant relationships. Only five papers reported using any frameworks, comprising grounded theory framework (n = 2), theory of planned behavior (n = 1), research justice framework (n = 1), and the patient and public engagement protocol (n = 1). DISCUSSION: A holistic approach to understanding the multifactorial experiences of Black mothers with preterm infants needs to be socio-culturally competent to ensure their diverse intersections and identities are accurately represented and understood. Rigorous research at the intersection of Black maternal health and the NICU hold promises for advancing maternal health equity in the United States.

Supporting and Enabling the Process of Innovation in Public Health: The Framework for Public Health Innovation.

This manuscript introduces a new framework for creating innovations in public health-the Framework for Public Health Innovation. The framework was developed through a longitudinal qualitative research study that investigated the process of creating innovative adolescent health programs. Interviews were conducted with a national sample of 26 organizations over two time points. Data collection focused on the process of innovative program development; organizational capacity; training; and technical assistance needs, successes, and barriers. The framework was developed and modified based on interview findings and expert advice; then, the final framework was validated with content experts. The framework illustrates a dynamic process of innovation that begins with dissatisfaction with the status quo, and then, illustrates three necessary components for innovation-space, process, and partnerships. Four categories of innovation, which range in complexity, are proposed: (1) creating a new component to an existing program, (2) adapting an existing program to meet new needs, (3) taking an alternative approach to addressing an existing program, and (4) reframing a health problem from a new perspective. As illustrated by a feedback loop, the resulting innovations disrupt the status quo. This model can be applied to any content area in public health and is useful for both research and practitioners.

Evaluating community-driven cardiovascular health policy changes in the United States using agent-based modeling.

Comprehensive smoke-free policy is a strategy to prevent cardiovascular disease (CVD) at a population-level; however, evaluating their long-term outcomes is difficult. This study used an agent-based model to estimate long-term impacts of a comprehensive smoke-free policy, as it was implemented in two communities, Arlington and Mesquite, Texas. The model predicted the percentage of myocardial infarction (MI), stroke, and diabetes in the population 10 and 20 years following policy adoption. In Arlington, the percentage of the population with these conditions each decreased by approximately 0.5% over 20 years; in Mesquite, the percentage of the population with diabetes, myocardial infarction (MI), and stroke decreased by 1.1%, 0.6%, and 0.3%, respectively, after 20 years. The results were statistically significant (p < 0.001). As an evaluation strategy, agent-based modeling can help researchers and practitioners estimate the potential long-term effects of policies and garner intervention support for implementation.

A program evaluation of the Innovative Teen Pregnancy Prevention Programs (iTP3) Project.

BACKGROUND: Teen pregnancy prevention in the United States has traditionally focused on the development, testing, and subsequent implementation of a set of evidence-based programs (EBPs), recommended nationally. However, these existing EBPs often do not prioritize the most at-risk or vulnerable populations. METHODS: The Innovative Teen Pregnancy Prevention Programs (iTP3) project was funded to facilitate the development of new, innovative programs to reach disparate populations. Through a mixed methods design, iTP3 evaluated the process and resulting innovative programs from five iterative cohorts of funded organizations, referred to as Innovators. iTP3 utilized both a traditional funding model with more traditional methods of capacity building assistance, but transitioned over time to a design-focused funding model in which organizations and individuals developed innovative programs through an intensive human centered design process. RESULTS: Evaluation results showed that the resulting portfolio of programs had differences in the types of programs resulting from the differing funding models. Notable differences among programs from the two funding models include program length, along with personnel, time, and resources needed to develop and manage. CONCLUSION: Both traditional and design funding models led to innovative programs, with notable differences in the development process and resulting programs.

Implementation evaluation of a collective impact initiative to promote adolescent health in Oklahoma County, USA.

BACKGROUND: The teenage birth rate in the USA has considerably decreased in recent decades; however, more innovative, collaborative approaches are needed to promote adolescent health and prevent teenage pregnancy at the community level. Despite literature on the promising results of the collective impact (CI) model for health promotion, there is limited literature on the model's ability to reduce teenage pregnancies in a community. The Central Oklahoma Teen Pregnancy Prevention Collaboration is applying the CI model to foster collaboration among multiple stakeholders with the goal of increasing community and organizational capacity to improve adolescent health outcomes. This paper reports the findings from the initiative's implementation evaluation, which sought to understand whether the CI model improved collaboration among organizations and understand barriers and facilitators that affected program delivery. METHODS: Program implementers and evaluators jointly developed research questions to guide the intervention and evaluation design. The Consolidated Framework for Implementation Research (CFIR) was used to assess program components including the intervention characteristics, organization setting, community setting, facilitator characteristics, and the process of implementation. Primary sources of data included performance measures, meeting observations (n = 11), and semi-structured interviews (n = 10). The data was thematically analyzed using CFIR constructs, community capacity domains, and the five constructs of CI. RESULTS: Key findings include the need for shortened meeting times for meaningful engagement, opportunities for organizations to take on more active roles in the Collaboration, and enhanced community context expertise (i.e., those with lived experience) in all Collaboration initiatives. We identified additional elements to the core constructs of CI that are necessary for successful implementation: distinct role identification for partner organizations and incorporation of equity and inclusivity into collaboration processes and procedures. CONCLUSIONS: Results from this implementation evaluation provide valuable insights into implementation fidelity, participant experience, and implementation reach of an innovative, systems-level program. Findings demonstrate the context and requirements needed to successfully implement this innovative program approach and CI overall. Additional core elements for CI are identified and contribute to the growing body of literature on successful CI initiatives.

Network analysis of a community-wide teenage pregnancy prevention initiative.

Although US teenage birth rates substantially decreased over the past two decades, it still remains the highest in the developed world. More innovative, community-wide initiatives are needed to combat the issue. In Oklahoma County, Oklahoma, the Central Oklahoma Teen Pregnancy Prevention Collaboration is utilizing the collective impact model to convene multiple organizations with the goal of making systems-level changes related to teenage pregnancy within the community. This study used an interorganizational network analysis to evaluate the current strength of relationships between organizations in the Collaboration. An interorganizational network survey assessed collaborative relationships (e.g. information sharing and joint planning) within the network. Using R software, network diagrams were developed to depict partner relationships, and network measures, including node-, group- and network-level measures, were calculated. The network depiction (n = 23) revealed that the network core was composed of organizations from multiple sectors, and the backbone organization served as the most central organization for most centrality measures. This study provides insight into how organizational relationships can be assessed in order to increase community capacity to address teenage pregnancy. Continuous monitoring of the strength of relationships is important to ensure success in achieving goals as well as collective impact.

Provision of contraceptive implants in school-based health centers: A cost-effectiveness analysis.

OBJECTIVE: To evaluate the cost-effectiveness of providing contraceptive implants in school-based health centers (SBHCs) compared to the practice of referring adolescents to non-SBHCs in New York City. STUDY DESIGN: We developed a microsimulation model of teen pregnancy to estimate the cost-effectiveness of immediate provision of contraceptive implants at SBHCs over a 3-year time horizon. Model parameters were derived from both a retrospective chart review of patient data and published literature. The model projected the number of pregnancies as well as the total costs for each intervention scenario. The incremental cost-effectiveness ratio was calculated using the public payer perspective, using direct costs only. RESULTS: The health care cost of immediate provision of contraceptive implants at SBHCs was projected to be $13,719 per person compared to $13,567 per person for delayed provision at the referral appointment over 3 years. However, immediate provision would prevent 78 more pregnancies per 1000 adolescents over 3 years. The incremental cost-effectiveness ratio for implementing in-school provision was $1940 per additional pregnancy prevented, which was less than the $4206.41 willingness-to-pay threshold. Sensitivity analyses showed that the cost-effectiveness conclusion was robust over a wide range of key model inputs. CONCLUSION: Provision of contraceptive implants in SBHCs compared to non-SBHCs is cost-effective for preventing unintended teen pregnancy. Health care providers and policymakers should consider expanding this model of patient-centered health care delivery to other locations.

Are health care providers making the most of patient encounters to promote HPV vaccination among cigarette smokers?

OBJECTIVE: To examine providers' HPV vaccine communication among adult cigarette smokers with household members aged ≤26 years. METHODS: In this cross-sectional study, we used 2017 Health Information National Trends Survey (HINTS 5, Cycle 1; N = 3191) data to derive a subsample (n = 725/3191; 22.7%) of adults with household members aged ≤26 years. Forward stepwise multivariable logistic regression analyses were performed to examine providers' HPV vaccine communication, adjusting for patients' smoking status (main independent variable); HPV awareness and knowledge; HPV vaccine awareness and beliefs; and sociodemographic characteristics that contribute to disparities in HPV vaccine coverage. RESULTS: Current/former smokers (35.0%) had lower HPV-related awareness/knowledge than nonsmokers (65%). Few reported providers discussed (27.4%) or recommended (24.0%) HPV vaccine. Non-Hispanic Whites who knew HPV was a sexually transmitted disease and heard of HPV vaccine were 2-6 times more likely to report provider HPV vaccine communication. Provider HPV vaccine communication differences by smoking status were not statistically significant. CONCLUSION: Providers' HPV vaccine communication was higher among adults who had higher HPV-related awareness/knowledge. Although active/passive exposure to cigarette smoke increases cervical cancer risk, providers' HPV vaccine communication was not increased for current/former smokers. PRACTICE IMPLICATIONS: Current/former smokers' HPV-related awareness/knowledge and providers' HPV vaccine communication need to be increased.