"I probably have access, but I can't afford it": expanding definitions of affordability in access to contraceptive services among people with low income in Georgia, USA.

BACKGROUND: Disparities in rates of contraceptive use are frequently attributed to unequal access to and affordability of care. There is a need to better understand whether common definitions of affordability that solely relate to cost or to insurance status capture the reality of individuals' lived experiences. We sought to better understand how individuals with low incomes and the capacity for pregnancy conceptualized one domain of contraceptive access-affordability --in terms of health system and individual access and how both shaped contraceptive care-seeking in the US South. METHOD: Between January 2019 to February 2020, we conducted twenty-five life-history interviews with low-income individuals who may become pregnant living in suburban counties in Georgia, USA. Interviews covered the ways individual and health system access factors influenced care-seeking for family planning over the life course. Interview transcripts were analyzed using a thematic analysis approach to identify experiences associated with individual and health system access. RESULTS: Affordability was identified as a major determinant of access, one tied to unique combinations of individual factors (e.g., financial status) and health system characteristics (e.g., cost of methods) that fluctuated over time. Navigating the process to attain affordable care was unpredictable and had important implications for care-seeking. A "poor fit" between individual and health system factors could lead to inequities in access and gaps in, or non-use of contraception. Participants also reported high levels of shame and stigma associated with being uninsured or on publicly funded insurance. CONCLUSIONS: Affordability is one domain of contraceptive access that is shaped by the interplay between individual factors and health system characteristics as well as by larger structural factors such as health and economic policies that influence both. Assessments of the affordability of contraceptive care must account for the dynamic interplay among multilevel influences. Despite the expansion of contraceptive coverage through the Affordable Care Act, low-income individuals still struggle with affordability and disparities persist.

Addressing the Community Resource and Social Service Needs of Families During the COVID-19 Pandemic: Perspectives of Home Visiting Staff and Clients in Georgia.

INTRODUCTION: Home visiting programs provide support services to families and their children to promote positive health outcomes. This study sought to describe strategies employed by home visiting programs during the early phase of the COVID-19 pandemic to address the community resource and social service needs of home visiting clients in Georgia. METHODS: We conducted a mixed methods study between December 2020 and April 2021 using online surveys and key informant interviews of home visiting staff and clients from 21 program sites. Structured content analysis was conducted of the triangulated data to elicit thematic findings. RESULTS: Due to the pandemic-induced economic conditions, clients expressed increased demand for housing, employment, and childcare support services. Staff experienced challenges with client referrals to these services because of interruptions in social service availability and transitions to virtual services. In response to these challenges, home visiting programs strengthened existing community partnerships and created new collaborations with local agencies to fill any gaps in services. DISCUSSION: Home visiting programs in Georgia provided critical linkages to community resources for families during the early phase of the pandemic. Preserving this essential home visiting service in future national emergencies will require improved coordination of community resources and social services.

Medication Abortion "Reversal" Laws: How Unsound Science Paved the Way for Dangerous Abortion Policy.

Objectives. To longitudinally examine the legal landscape of laws requiring abortion patients be informed about the possibility of medication abortion (MAB) "reversal" (in quotes as it does not refer to an evidence-based medical procedure). Methods. We collected legal data on enacted state MAB-reversal laws across all 50 US states and Washington, DC, (collectively, states) from 2012 through 2021. We descriptively analyzed these laws to identify legal variation over time and geography, and conducted a content analysis to identify qualitative themes and patterns in MAB-reversal laws. Results. As of 2021, 14 states (27%)-mostly in the midwestern and southern United States-have enacted MAB-reversal laws. States largely use explicit language to describe reversal, require patients receive information during preabortion counseling, require physicians or physicians' agents to inform patients, instruct patients to contact a health care provider or visit "abortion pill reversal" resources for more information, and require reversal information be posted on state-managed Web sites. Conclusions. Reversal laws continue a dangerous precedent of using unsound science to justify laws regulating abortion access, intrude upon the patient‒provider relationship, and may negatively affect the emotional and physical health of patients seeking an MAB. (Am J Public Health. 2023;113(2):202-212. https://doi.org/10.2105/AJPH.2022.307140).

Implementation of Enhanced Recovery Protocols for Gastrointestinal Surgery in Children: Practical Tools From Key Stakeholders.

INTRODUCTION: We explored patient, caregiver, and provider recommendations for development of a tool kit to implement enhanced recovery protocols (ERPs) for pediatric patients undergoing gastrointestinal surgery. ERPs are widely used for adults to decrease hospital length of stay, hospital costs, and complications while hastening patient recovery after surgery. With limited data available for ERPs among pediatric populations informed modification of adult ERPs is needed to facilitate successful implementation for pediatric surgery. METHODS: Using a qualitative research design, semistructured interviews were conducted with hospital-based teams including surgeons, anesthesiologists, gastroenterologists, nursing, and physician assistants. Four in-person focus groups were held at two pediatric hospitals with patients and caregivers. Codes were developed and applied to interview and focus groups transcripts for structural content analysis. Thematic analysis guided by the Active Implementation Framework, included recommendations that informed ERP implementation tool kit development. RESULTS: Key components of the ERP tool kit included the need for a structured and systematic approach, leadership support from key champions, and buy-in from surgical partners and hospital management. Providers identified the need for multimodal educational materials on ERP elements for staff and patients; use of uniform checklists, care sets and an electronic repository to collect outcome data for quality assurance assessment. Patients and caregivers endorsed expansion of the team to include child-life specialists, nutritionists, and patient-parent supporters to help navigate the surgical experience. CONCLUSIONS: This study is the first to leverage key input from patients, caregivers, and providers to identify practical components for an ERP implementation tool kit for children undergoing gastrointestinal surgery.

Maternal health equity in Georgia: a Delphi consensus approach to definition and research priorities.

BACKGROUND: Pregnancy-related mortality in the United States is the greatest among all high-income countries, and Georgia has one of the highest maternal mortality rates-almost twice the national rate. Furthermore, inequities exist in rates of pregnancy-related deaths. In Georgia, non-Hispanic Black women are nearly 3 times more likely to die from pregnancy-related complications than non-Hispanic White women. Unlike health equity, a clear definition of maternal health equity is lacking, overall and in Georgia specifically, but is needed to reach consensus and align stakeholders for action. Therefore, we used a modified Delphi method to define maternal health equity in Georgia and to determine research priorities based on gaps in understanding of maternal health in Georgia. METHODS: Thirteen expert members of the Georgia Maternal Health Research for Action Steering Committee (GMHRA-SC) participated in an iterative, consensus-driven, modified Delphi study comprised of 3 rounds of anonymous surveys. In round 1 (web-based survey), experts generated open-ended concepts of maternal health equity and listed research priorities. In rounds 2 (web-based meeting) and 3 (web-based survey), the definition and research priorities suggested during round 1 were categorized into concepts for ranking based on relevance, importance, and feasibility. Final concepts were subjected to a conventional content analysis to identify general themes. RESULTS: The consensus definition of maternal health equity created after undergoing the Delphi method is: maternal health equity is the ultimate goal and ongoing process of ensuring optimal perinatal experiences and outcomes for everyone as the result of practices and policies free of interpersonal or structural bias that tackle current and historical injustices, including social, structural, and political determinants of health impacting the perinatal period and life course. This definition highlights addressing the current and historical injustices manifested in the social determinants of health, and the structural and political structures that impact the perinatal experience. CONCLUSION: The maternal health equity definition and identified research priorities will guide the GMHRA-SC and the broader maternal health community for research, practice, and advocacy in Georgia.

Age- and Sex-Specific Needs for Children Undergoing Inflammatory Bowel Disease Surgery: A Qualitative Study.

INTRODUCTION: The use of enhanced recovery protocols (ERP) is extending to pediatric surgical populations, such as patients with inflammatory bowel diseases (IBDs). Given the variation in age- and sex-specific characteristics of pediatric IBD patients, it is important to understand the unique needs of subgroups, such as male versus female or preadolescent versus older patients, when implementing ERPs. We gathered clinician, patient, and caregiver perspectives on age- and sex-specific needs for children undergoing IBD surgery. METHODS: We used semistructured interviews and focus groups to assess ERP needs and perceived differences in needs between preadolescent (10-13 y), older (14-19 y), male, and female IBD patients. Participants included clinicians, patients who had recent IBD surgery, and patients' caregivers. RESULTS: Forty-eight clinicians, six patients, and eight caregivers participated. Three broad categories of themes emerged: concerns, needs, and experiences related to the (1) surgical care process; (2) continuum of IBD care; and (3) suggestions to make surgical care more patient centered. With regard to surgical care processes, stakeholders reported different communication needs for preadolescent and older children. Key themes about the continuum of IBD care were the need (1) for support from child life specialists and (b) to address young women's health issues. Suggestions to make surgical care more patient centered included providing older children with patient experiences that reflect their perspective as young adults. CONCLUSIONS: The findings highlight the need to adopt a patient-centered approach for ERP use that actively addresses age- and sex-specific factors while engaging patients and caregivers as partners with clinicians to improve surgical care for children with IBD.

Prior Authorization Policies and Preferred Drug Lists in Medicaid Plans: Stakeholder Perspectives on the Implications for Youth with ADHD.

This qualitative study describes how Medicaid policies create challenges for the delivery and receipt of mental health treatment for low-income youth in Georgia. We conducted focus groups with caregivers of Medicaid-enrolled children with ADHD and semi-structured interviews with providers and administrators at four safety net clinics that provided mental health care to these youth. Stakeholders reported that prior authorization policies for psychosocial services, restrictiveness of preferred drug lists, and changes in preferred drug lists in Medicaid plans created barriers to treatment continuity and quality for youth with ADHD and led to more administrative burden for safety-net clinics serving these youth.

Implementation of Florida Long Term Care Emergency Preparedness Portal Web Site, 2015-2017.

We built an online emergency preparedness Web site for Florida nursing homes after an earlier study revealed gaps in information and a lack of available preparedness resources for long-term care providers. The Long Term Care Emergency Preparedness Portal ( www.ltcprepare.org ) was launched in January 2015. We assessed its use and sought suggestions for improvement. Findings indicate that long-term care providers in Florida regularly use the Web site, and they welcome the opportunity to further leverage technology to aid their disaster planning.

Revisiting safe sleep recommendations for African-American infants: why current counseling is insufficient.

The American Academy of Pediatrics recommends that children be placed in the supine position on firm bedding and not bed share with parents or other children. Health professionals increasingly understand that many African-American parents do not follow these recommendations, but little research exists on provider reactions to this non-compliance. This study was intended to better understand how low-income, African-American mothers understand and act upon safe sleep recommendations for newborns and how providers counsel these mothers. We conducted focus groups with 60 African-American, low-income, first-time mothers and telephone interviews with 20 providers serving these populations to explore provider counseling and patient decision making. The large majority of mothers reported understanding, but not following, the safe-sleeping recommendations. Key reasons for non-compliance included perceived safety, convenience, quality of infant sleep and conflicting information from family members. Mothers often take measures intended to mitigate risk associated with noncompliance, instead increasing SIDS risk. Providers recognize that many mothers are non-compliant and attribute non-compliance largely to cultural and familial influence. However, few provider attempts are made to mitigate SIDS risks from non-compliant behaviors. We suggest that counseling strategies should be adapted to: (1) provide greater detailed rationale for SIDS prevention recommendations; and (2) incorporate or acknowledge familial and cultural preferences. Ignoring the reasons for sleep decisions by African-American parents may perpetuate ongoing racial/ethnic disparities in SIDS.

Facilitators and barriers to cervical cancer screening, diagnosis, and enrollment in Medicaid: experiences of Georgia's Women's Health Medicaid Program enrollees.

Although cervical cancer incidence and mortality rates have declined in the USA, African American women have a higher incidence rate of cervical cancer and a higher percentage of late-stage diagnosis than white women. Previous analyses by the authors showed that, even after adjusting for age, provider location, and availability, African American women were almost half as likely as white women to be diagnosed or enter Medicaid while at an early stage of their cervical cancer. To understand why these differences exist, we undertook a qualitative examination of the cervical cancer experiences of women enrolled in Georgia's Women's Health Medicaid Program (WHMP). Life history interviews were conducted with 24 WHMP enrollees to understand what factors shaped their cervical cancer experiences, from screening through enrollment in Medicaid. We also examined whether these factors differed by race in order to identify opportunities for increasing awareness of cervical cancer screening among underserved women. Results suggest that many women, especially African Americans, lacked understanding and recognition of early symptoms of cervical cancer, which prevented them from receiving a timely diagnosis. Additionally, participants responded positively to provider support and good communication but wished that their doctors explained their diagnosis more clearly. Finally, women were able to enroll in Medicaid without difficulty due largely to the assistance of clinical staff. These findings support the need to strengthen provider education and public health efforts to reach low-income and minority communities for screening and early detection of cervical cancer.

"So that I can trust them with my body:" How people with low incomes who may become pregnant define and prioritize quality reproductive health care.

OBJECTIVES: As part of a larger mixed-methods study to better define equity in access to sexual and reproductive health (SRH) care in Georgia, this analysis sought to understand: (1) how individuals define quality care for their SRH services; and (2) how quality of care is salient in their SRH care-seeking. STUDY DESIGN: From January 2019 to February 2020, we conducted life history interviews with individuals with the capacity to become pregnant in suburban areas in Georgia. We analyzed interviews using thematic analysis. RESULTS: SRH care quality was shaped by experiences with health center environment, with providers, and with staff. Study participants emphasized elements associated with trusted SRH care such as showing compassion, respecting and non-judging, taking time, providing information, and assuring agency. Participants also voiced a desire for holistic care that addressed the lived experiences of the individual. Participants took quality of care into account when care-seeking but sometimes had to weigh out preferences for quality with issues of affordability. CONCLUSIONS: Access to quality person-centered care is an essential component of realized access to SRH services. Measures of equitable access and quality should account for experiences of quality care that include both provider and staff interactions as well as the larger healthcare environment and ability to use quality care despite financial constraints. IMPLICATIONS: Quality family planning care should involve both clinicians and staff to incorporate showing compassion, providing respectful and non-judgmental care, taking time with patients, providing information, assuring agency in decision-making, as well as addressing the lived experiences of individuals.

Investigating the Barriers and Facilitators to Using Antiretroviral Therapy among Women Living with HIV in Plateau State, Nigeria.

BACKGROUND: Women and girls account for more than 50% of the global HIV population. In Nigeria, the proportion of women living with HIV on long-term antiretroviral therapy (ART) has been on the rise. Despite this, little research exists on their experiences regarding antiretroviral therapy use, especially for women living with HIV (WLHIV) in Plateau State, Nigeria. This study investigates the barriers and facilitators influencing antiretroviral therapy use among women living with HIV. METHODS: This study employed a qualitative research design, using focus groups, and included women (female sex workers, pregnant and non-pregnant women living with HIV) and the male partners of serodiscordant couples. Eligibility criteria were being 18 years of age or older, on antiretroviral therapy for more than one year/on pre-exposure prophylaxis (PrEP) for more than one month, and speaking English, Hausa, or both. Data coding utilized both inductive and deductive approaches, and standard content analysis was applied to develop emerging themes. RESULTS: Of the 106 participants, 88 were women living with HIV, and 18 were men in serodiscordant couples. The first facilitator shared by the participants was feeling healthier and stronger due to the antiretroviral therapy, which was also expressed by the male participants on PrEP as feeling good while taking the drug. Additional facilitators shared by the participants included weight gain and having a more positive outlook on life. Participants also disproportionately described barriers to using antiretroviral therapy, including experiences with emotional challenges, physical discomfort, and side effects of ART. Such barriers were linked to feelings of past regret, frustration, and disappointment. CONCLUSION: This study underscores the significance of maintaining a positive perspective on ART use, demonstrated by the connection between a positive outlook and weight gain, and highlights the hurdles that Plateau State's women living with HIV face in adhering to antiretroviral therapy. Policymakers and healthcare providers can utilize these findings to formulate targeted strategies aimed at minimizing identified barriers and enhancing antiretroviral therapy utilization among this population via peer- support groups, economic empowerment, and psychosocial support.

Person-centered hospital discharge data: Essential existing infrastructure to enhance public health surveillance of maternal substance use disorders in the midst of a national maternal overdose crisis.

OBJECTIVES: As crises of drug-related maternal harms escalate, US public health surveillance capacity remains suboptimal for drug-related maternal morbidities. Most state hospital discharge databases (HDDs) are encounter-based, and thus limit ascertainment of morbidities to delivery visits and ignoring those occurring during the 21 months spanning pregnancy and postpartum year. This study analyzes data from a state that curates person-centered HDD to compare patterns of substance use disorder (SUD) diagnoses at delivery vs. the full 21 pregnancy/postpartum months, overall and by maternal social position. METHODS: Among people who experienced an in-hospital birth in New York State between 9/1/2016 and 1/1/2018 (N = 330,872), we estimated SUD diagnosis (e.g., opioids, stimulants, benzodiazepines, cannabis) prevalence at delivery; across the full 9 months of pregnancy and 12 postpartum months; and by trimester and postpartum quarter. Risk ratio and risk difference estimated disparities by race/ethnicity, age, rurality, and payor. RESULTS: The 21-month SUD prevalence rate per 100,000 was 2671 (95% CI 2616-2726), with 31% (29.5%-31.5%) missing SUD indication when ascertained at delivery only (1866; 95% CI 1820-1912). Quarterly rates followed a roughly J-shaped trajectory. Structurally marginalized individuals suffered the highest 21-month SUD prevalence (e.g., Black:White risk ratio=1.80 [CI:1.73-1.88]). CONCLUSION: By spanning the full 21 months of pregnancy/postpartum, person-centered HDD reveal than the maternal SUD crisis is far greater than encounter-based delivery estimates had revealed. Generating person-centered HDD will improve efforts to tailor interventions to help people who use drugs survive while pregnant and postpartum, and eliminate inequities.

Planning for the forgotten fourth trimester of pregnancy: A parallel group randomized control trial to test a postpartum planning intervention vs. standard prenatal care.

BACKGROUND: Black and brown birthing people experience persistent disparities in adverse maternal health outcomes, partially due to inadequate perinatal care. The goal of this study is to design and evaluate a patient-centered intervention for obstetric patients with one or more cardiometabolic risk factors for severe maternal morbidity [gestational diabetes, diabetes mellitus, hypertensive disorders of pregnancy (chronic hypertension, preeclampsia, eclampsia, or gestational hypertension), or preconception obesity (BMI > 30)] to promote postpartum visit attendance. METHODS: To address identified unmet needs for postpartum support and barriers to postpartum care, we developed 20 thematic postpartum planning modules, each with corresponding patient educational materials, community resources, care coordination protocols, and clinician support tools (decision aids, electronic medical record prompts and fields). During prenatal care encounters, a research coordinator delivers the educational content (in English or Spanish), facilitates the participant's planning and shared decision-making, provides the participant with resources, and documents decisions in the electronic medical record. We will randomize 320 eligible patients with a 1:1 ratio to the intervention or standard prenatal care and evaluate the impact on postpartum visit attendance at 4-12 weeks and secondary outcomes (postpartum mental health, perceived future maternal and cardiometabolic risk, contraceptive use, primary care use, readmission, and patient satisfaction with care). DISCUSSION: Through engagement with patients and community stakeholders, we developed a guideline-based, locally tailored intervention to address drivers of engagement with postpartum care for high-risk obstetric patients. If demonstrated to be effective, the educational materials and electronic medical record based-tool can be adapted to other settings. TRIAL REGISTRATION: This trial was registered on ClinicalTrials.gov (NCT05430815) on June 23, 2022.

Efforts by commercial health plans to increase Chlamydia trachomatis screening among their members.

BACKGROUND: The screening rate for Chlamydia trachomatis (Ct) is below 38% nationally, despite the high prevalence of Ct nationally and the low cost of both the screening test and the treatment. The purposes of this study are (a) to ascertain what activities commercial health plans have attempted (if any) to increase their Ct screening rates and (b) to identify barriers to improving Ct screening rates in commercial health plans. METHODS: Qualitative research methods were used, including structured interviews. In-depth telephone interviews with commercial health plans were conducted to identify health plan activities that led to high Ct screening rates by providers. Plans were selected, which were either in the top or in the bottom quarter of all plans or had either an increase or decrease in Ct screening rates of at least 3 percentage points over the previous 2 to 3 years. Interviews were restricted to plans reporting Ct screening rates to the National Committee for Quality Assurance for at least 3 years, plans with enrollment of at least 500 commercially insured women aged 15 to 26 years, and plans that were not staff model-managed care plans. A total of 35 structured interviews were completed with a response rate of 64%. RESULTS: Overall Ct screening rates in commercial health plans are quite low, with a median rate of 35%. All interviewed plans-both successful and not successful-reimbursed for Ct screening and used clinical guidelines. All but 3 plans had some type of intervention in place designed to improve Ct screening rats. The interventions varied-some aimed at providers, others at patients, and others at data collection-but the health plans were actively trying to improve screening rates. Health plans identified several barriers to improving screening rates in the commercially insured population. These include difficulties in identifying sexually active members for screening, limited health plan resources to target the problem, concerns about contacting minors, and cultural barriers to discussing sexually transmitted diseases. CONCLUSIONS: Both high- and low-performing plans are actively trying to increase the Ct screening rates. However, efforts to date have not been successful, suggesting the need for alternative approaches to address existing barriers.

Quality improvement training: experiences of frontline staff.

PURPOSE: Healthcare organizations have employed numerous strategies to promote quality improvement (QI) initiatives, yet little is known about their effectiveness. In 2008, staff in one organization developed an in-house QI training program designed for frontline managers and staff and this article aims to report employee perspectives. DESIGN/METHODOLOGY/APPROACH: Qualitative interviews were conducted with 22 course participants to examine satisfaction, self-assessed change in proficiency and ability to successfully engage with QI initiatives. Sampling bias may have occurred as the participants volunteered for the study and they may not represent all course participants. Recall bias is also possible since most interviews took place one year after the course was completed to assess long-term impact. Respondents were asked to self-rate their pre- and post-course knowledge and skill, which may not represent what was actually learned. FINDINGS: Informants reported that the course expanded their QI knowledge and skills, and that supervisor support for the course was essential for success. Additionally, the course QI project provided participants with an opportunity to translate theory into practice, which has the potential to influence patient outcomes. PRACTICAL IMPLICATIONS: Several lessons for future QI training can be gleaned from this evaluation, including respondent opinions that it is challenging to offer one program when participants have different QI knowledge levels before the course begins, that "booster sessions" or refresher classes after the course ends would be helpful and that supervisor support was critical to successful QI-initiative implementation. ORIGINALITY/VALUE: This study conducts in-depth interviews with QI course participants to elicit staff feedback on program structure and effectiveness. These findings can be used by QI educators to disseminate more effective training programs.

Stakeholder perspectives on the advantages and challenges of expanded school mental health services for publically-insured youth.

Although partnerships between community-based mental health (MH) organizations and school systems to deliver MH services on school grounds (i.e., expanded school mental health, ESMH services) are growing, qualitative research is needed about stakeholders' perspectives on ESMH services. This study collected qualitative data from caregivers, MH providers, and MH administrators recruited from three MH organizations to understand their perspectives regarding potential advantages and challenges associated with ESMH services. The three MH organizations were located in three regions of Georgia and the majority of youth served by the organizations were enrolled in Medicaid. We conducted four focus groups with 33 caregivers and 13 semistructured interviews with MH administrators and providers, and we implemented a thematic content analysis. Caregivers, providers, and MH administrators described how ESMH services could improve MH services by (a) facilitating appointment attendance through the reduction of logistical barriers to care (including geographic barriers, missed class time, and missed work time) and (b) enhancing communication between providers and teachers. However, some participants also described logistical issues with ESMH services including school space constraints and challenges scheduling appointments. In addition, some caregivers expressed concerns about peer stigma if MH services are delivered at school (vs. the clinic). Providers and MH administrators discussed problems with low caregiver engagement and challenges collaborating with school personnel that stem from lack of understanding of MH problems and treatment. Although ESMH services can improve MH treatment among low-income youth, MH providers and MH administrators may consider collaborating with school personnel to proactively develop strategies to address challenges to its success. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Adaptations to the Learning Environment for Elementary School Children in Georgia during the COVID-19 Pandemic.

In March 2020, the rapid spread of COVID-19 led to physical school closures across the United States. Schools quickly transitioned to a remote and/or virtual learning environment. This transition had implications for students at all levels of education, especially for those most vulnerable and school-dependent for ancillary resources. The goal of this qualitative exploratory research study was to examine how public elementary schools in Georgia adapted their learning environments for students in kindergarten through third grade during the early phase of the COVID-19 pandemic. Data collection activities included school demographic surveys, parent surveys, interviews with twelve school administrators, and six focus groups with twenty-six parents. The participants discussed schools' preparation capabilities, implementation of learning modalities, and resources for students and families. Most school personnel described the new virtual teaching demands as a hurdle for their teachers and identified several academic consequences stemming from inadequate technology access or training, such as student absenteeism and lower teaching performance. Schools lacked appropriate preparation as well as limited resources to transition to virtual learning. The COVID-19 pandemic aggravated pre-existing education and technology resource disparities for students and families of low socio-economic status or who live in rural areas. Findings from this study provide educators with information regarding deficiencies in the learning environment and provide recommendations for ongoing academic remedial efforts. Additionally, this study provides important context for the shortcomings of the COVID-19 learning environments and highlights the need to strengthen school community infrastructure and emergency planning.

Implementation of Title X Family Planning Services in Primary Care: A Qualitative Study of a Primary Care Network in Georgia.

CONTEXT: There is increasing interest and value in integrating family planning services into primary care. Title X services provide an opportunity to expand low-cost access to these services. This study sought to identify and describe implementation factors that influenced the integration of a package of Title X services into a unique primary care setting within a Georgia primary care network whose community health center sites are primarily federally qualified health centers. METHODS: We used an implementation science approach and were guided by the Consolidated Framework for Implementation Research. From December 2019 to September 2020, we conducted interviews with administrators and providers working at grantee and sub-grantee organizations about their experiences integrating Title X services into their existing practice. RESULTS: Factors associated with the Inner Setting were especially important for integrating Title X in these settings. Participants identified specific needs related to resources such as electronic medical record (EMR) and reporting templates. Contextually specific clinical training for provision of long-acting reversible contraception and sexual health counseling, as well as administrative training for reporting and documentation efforts, was particularly needed. Grantee and sub-grantee organizations were able to leverage internal and external networks and adaptations to the intervention to successfully implement Title X services and to expand reach to new clients. CONCLUSIONS: Integrating family planning into primary care may expand access to low-income and underserved populations. Approaches that incorporate flexibility and provide tailored resources for primary care settings such as EMR and reporting templates and trainings, and that leverage multiple forms of support and knowledge sharing, may be particularly important for helping to implement Title X services.

Factors That Influence Sleep Behaviors of High School Students: Findings From a Semi-Rural Community in Georgia.

BACKGROUND: Inadequate sleep has been shown to have detrimental effects on academic performance, physical, mental, and emotional health among adolescents. Factors that influence sleep have been identified. However, most literature is currently limited to urban settings. This study sought to identify factors that influence sleep habits among high school students in a semi-rural community. METHODS: Twelve focus groups were conducted in-person with separate groups of students, parents, and school staff in October 2019. Discussions focused on sleep experiences, knowledge, environment, and factors influencing sleep. Data were coded using grounded theory approach. Themes were identified through summative content analysis. RESULTS: Four major themes were identified: (1) inadequate sleep adversely affects academic performance and emotional health; (2) students face a gap in knowledge regarding sleep duration; (3) academic and nonacademic activities compete with sleep needs; and (4) night-time use of technology negatively influences sleep habits. CONCLUSIONS: Our findings suggest that high school students do not get adequate sleep, largely due to the demands of academic and extracurricular activities and the use of electronics at night. These results can guide the development of targeted sleep education and intervention programs.