Systems-Level Evaluation of Safe Routes to School Policies in El Paso, Texas: A Modeling Study on Health and Economic Outcomes.

Safe Routes to School (SRTS) policies are linked to physical health benefits for school-age children; however, few studies have assessed long-term impacts on cardiovascular disease (CVD). This study used systems science methods to predict long-term health and economic impact of SRTS among school-age children in El Paso County, Texas. We developed an agent-based model containing 2 modules: the pedestrian injury module and the CVD module. We simulated 10 000 school-age children under 2 scenarios-SRTS policies implemented and no SRTS policies implemented-and then calculated pedestrian injuries, pedestrian injury-related deaths, coronary heart disease (CHD) and stroke events, and health care costs. When SRTS policies were implemented, the model estimated 157 fewer CHD cases and 217 fewer stroke cases per 10 000 people and reduced CVD-related health care costs ($13 788 per person). The model also predicted 129 fewer pedestrian injuries and 1.3 injury-related deaths per 10 000 people and $2417 savings in injury-related health care costs. SRTS could save an estimated $16 205 per person in health care costs. This simulation shows SRTS in El Paso County could prevent pedestrian injuries among school-age children and protect cardiovascular health in the long term. Our findings provide evidence for practitioners and policy makers to advocate for SRTS policies at the local level.

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.

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.

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.

Participation in Project ECHO to advance rural primary care providers' ability to address patient mental health needs.

The COVID-19 pandemic shed light on the burden of behavioral health conditions prevalent in the United States (U.S.). Consequently, there is a behavioral healthcare provider shortage, particularly in rural areas, to support this need. Recently, primary care providers (PCPs) have shifted to incorporate behavioral health to their practice. However, many PCPs lack knowledge and skills to successfully manage their patients' behavioral health conditions. In response to the need for effective behavioral healthcare across the U.S. Weitzman ECHO launched the Advanced Primary Care (APC ECHO) Adult Psychiatry Module to provide continuing education (CE) for rural PCPs. This study presents the results from the APC ECHO pilot to demonstrate how CE can support PCPs in addressing their patients' mental health needs. Evaluators used a one-group repeated measures study design to assess the APC ECHO Module and understand learner outcomes and individual practice changes. Participant characteristics and individual practice changes were summarized using descriptive statistics, with support from open-ended responses to illustrate findings. Repeated measures analyses of covariance were applied to compare the differences in pre- and post-module learner outcomes. A total of 18 providers participated in the study, with the majority encompassing medical providers (72.2%). There was a significant increase in knowledge (pre-module: 21.11 + 6.99; post-module: 25.08 + 5.66; p < .01), self-efficacy (pre-module: 6.89 + 3.05; post-module: 9.78 + 3.25; p < .01), and skills (pre-module: 7.67 + 4.03; post-module: 10.06 + 3.23; p < .05) gained over the duration of the ECHO module. Additionally, participants indicated they are applying best practices learned through the module to their patients experiencing psychiatric conditions (3.96 + 0.09). This study suggests that tailored CE for PCPs can promote an increase in knowledge, self-efficacy, and skills to apply best practices when treating patients with behavioral health conditions. This, in turn, allows patients to receive more comprehensive care and mitigates access barriers, especially for rural populations.

A multi-level analysis of prevalence and factors associated with caesarean section in Nigeria.

The choice of caesarean section (CS) plays a significant role in maternal and neonatal health. However, suboptimal CS uptake suggests unmet obstetric care leading to adverse maternal and neonatal health. Considering that maternal health problems in Nigeria remain a public health problem, this present study aims to assess the prevalence and multilevel factors associated with caesarean section among women of reproductive age in Nigeria. Data from the 2018 Nigeria Demographic and Health Survey were analysed. Our analyses included 19,964 women of reproductive age, with their last birth within five years preceding the survey. Multilevel logistic regression analysis was carried out to examine the predictors of the caesarean section in Nigeria. The prevalence of CS among women of reproductive age in Nigeria was 3.11%. Women from the Yoruba ethnic group [aOR = 0.52; 95%(CI = (0.32-0.84)], with two children [aOR = 0.67; 95%(CI = 0.52-0.88)], three children [aOR = 0.49; 95%(CI = 0.36-0.66)], four children and above [aOR = 0.34; 95%(CI = 0.26-0.46)], those who practised Islam [aOR = 0.74; 95%(CI = (0.56-0.99)], and those that had a normal weighted baby [aOR = 0.73; 95%(CI = 0.60-0.99)] were less likely to report having a CS in Nigeria compared to those from Hausa/Fulani ethnic group, those who had one child, those who practised Christianity, and those who had a high weighted baby. Also, women residing in rural areas [aOR = 0.79; 95% (CI = (0.63-0.99)] and the South-South [aOR = 0.65; 95%(CI = (0.46-0.92)] were less likely to have CS compared to those residing in urban areas and North Central. The study concluded that several individual and community-level factors, such as religious belief, number of children, ethnicity, place of residence, and region of residence, were associated with CS utilisation in Nigeria. Our study highlights the need for different regional, local, and cultural contexts for evidence-based policy and programmatic efforts to facilitate equitable access to a caesarean section in Nigeria.

Sociodemographic factors and perceived patient-provider communication associated with healthcare avoidance among women with psychological distress.

Objective: To establish the extent to which psychological distress influences health avoidance behavior among women, controlling for patient provider communication and sociodemographic characteristics. Methods: Data from the 2019 Health Information National Trends Survey (HINTS 5, Cycle 3) was analyzed to obtain healthcare avoidance behavior among women aged 18 and older (n = 2788). Weighted descriptive, bivariate, and multivariable logistic regression models were conducted. Results: Approximately 649 women or 1 in 4 women (26.7% weighted prevalence; 95% Confidence Interval [CI] 0.23%-0.29%) avoided healthcare in the past 12 months. Non-Hispanic white (62.8%) and married (55.4%) women represented a higher proportion of the sample. Bivariate analysis revealed that the odds of reporting healthcare avoidance among women with mild, moderate, and severe psychological distress (Odds Ratio [OR]: 2.26, 95% CI: 1.45-3.53, p = 0.001; OR: 3.88, 95% CI: 2.29-6.56, p < 0.001; OR: 3.08, 95% CI: 1.81-5.23, p < 0.001) was significantly higher compared to those with none-minimal psychological distress. In the adjusted model, women with moderate and severe psychological distress (Adjusted OR [AOR]:3.15, 95% CI: 1.55-6.38, p = 0.002; AOR: 2.24, 95% CI: 1.10-4.92, p = 0.044) were more likely to report healthcare avoidance than those experiencing none-minimal psychological distress. Furthermore, increasing patient-provider communication score (AOR: 0.91, 95% CI: 0.87-0.96, p < 0.001) reduced the likelihood of healthcare avoidance. Among the sociodemographic variables assessed, being younger (18-49 years) and having less than a high school degree significantly increased the chances of avoiding healthcare. Conclusion: A high proportion of women with psychological distress avoid necessary healthcare. Patient-provider communication quality, increasing age, and being a high school student contribute to healthcare avoidance in women. Innovation: Strategies to improve health service utilization must address healthcare avoidance by developing effective health communication targeted at women with psychological distress.

The health and economic impact of the Tobacco 21 Law in El Paso County, Texas: A modeling study.

In December 2019, the US federal Tobacco 21 (T21) law passed to raise the minimum legal purchase age for tobacco products from 18 to 21 years. Preliminary evidence suggests that the T21 law will restrict youth access to tobacco products, leading to decreases in tobacco use over their lifetime. This study expands the science through the use of systems modeling by linking decreases in youth tobacco use in El Paso County, Texas, due to the T21 law implementation, to potential cardiovascular health (CVH) benefits and health care cost reductions. Using a smoking behavior and cardiovascular disease agent-based model, we projected the T21 law's long-term effects on smoking prevalence and CVH outcomes in El Paso County, Texas. The estimated smoking prevalence in El Paso County, Texas, decreased by 2.7% among 18-24 year olds and by 5.2% among 25-44 year olds in 20 years with T21 law implementation (p < 0.01 for both population groups). By reducing tobacco use, the T21 law could prevent 5.4 coronary heart disease events per 1,000 adults and 6.1 S events per 1,000 adults over a lifetime. The model estimated a reduction in lifetime health care costs from $42,929 per person without T21 law to $41,985 per person with the policy. This study provides further evidence for policymakers and communities to understand the potential health and economic impacts of the federal T21 law at the local level. Results emphasize the need for comprehensive policy implementation and enforcement to produce its intended impact on health outcomes.

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.

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.

Narrative Analysis of Childbearing Experiences During the COVID-19 Pandemic.

PURPOSE: The COVID-19 pandemic has disrupted health care delivery and services around the world causing rapid changes to maternity care protocols and pregnant women to give birth with tight restrictions and significant uncertainties. There is a gap in evidence about expectant and new mothers' experiences with birthing during the pandemic. We sought to describe and understand pregnant and new mothers' lived experiences during the COVID-19 pandemic using authentic birth stories. STUDY DESIGN AND METHODS: Using a narrative analysis framework, we extracted relevant YouTube birth stories using predetermined search terms and inclusion criteria. Mothers' birth stories were narrated in their second or third trimester or those who had recently given birth during the pandemic. Birth stories were analyzed using an inductive and deductive approach to capture different and salient aspects of the birthing experience. RESULTS: N = 83 birth stories were analyzed. Within these birth stories, four broad themes and 13 subthemes were identified. Key themes included a sense of loss, hospital experiences, experiences with health care providers, and unique experiences during birth and postpartum. The birth stories revealed that the COVID-19 pandemic brought unexpected circumstances, both positive and negative, that had an impact on mothers' overall birthing experience. CLINICAL IMPLICATIONS: Results provided a detailed description of women's lived experience with giving birth during the COVID-19 pandemic. Maternity nurses should try to provide clear communication and compassionate patient-centered care to relieve women's anxieties about uncertain and unpredictable policy changes on COVID-19 as the pandemic continues to evolve.

Social-Ecological Barriers to Access to Healthcare for Adolescents: A Scoping Review.

Access to healthcare for adolescents is often overlooked in the United States due to federal and state-sponsored insurance programs such as Medicaid and the Children's Health Insurance Program. While these types of programs provide some relief, the issue of healthcare access goes beyond insurance coverage and includes an array of ecological factors that hinder youths from receiving services. The purpose of this scoping review was to identify social-ecological barriers to adolescents' healthcare access and utilization in the United States. We followed the PRISMA and scoping review methodological framework to conduct a comprehensive literature search in eight electronic databases for peer-reviewed articles published between 2010 and 2020. An inductive content analysis was performed to thematize the categories identified in the data extraction based on the Social-Ecological Model (SEM). Fifty studies were identified. Barriers across the five SEM levels emerged as primary themes within the literature, including intrapersonal-limited knowledge of and poor previous experiences with healthcare services, interpersonal-cultural and linguistic barriers, organizational-structural barriers in healthcare systems, community-social stigma, and policy-inadequate insurance coverage. Healthcare access for adolescents is a systems-level problem requiring a multifaceted approach that considers complex and adaptive behaviors.