Development of a New Measure of Housing Security: The REDD-CAT Housing Security Measure.

BACKGROUND: Housing security is a key social determinant of behavior related to health outcomes. OBJECTIVE: The purpose of this study was to develop a new patient-reported outcome measure that evaluates aspects of housing security for use in the Re-Engineered Discharge for Diabetes-Computer Adaptive Test (REDD-CAT) measurement system. DESIGN: Qualitative data, literature reviews, and cross-sectional survey study. PARTICIPANTS: A total of 225 people with T2DM provided responses to the items in this item pool. MAIN MEASURES: A new item pool that evaluates important aspects of housing security was developed using stakeholder data from focus groups of persons with T2DM. KEY RESULTS: For the Housing Affordability scale, factor analysis (both exploratory and confirmatory) supported the retention of six items. Of these items, none exhibited sparse cells or problems with monotonicity; no items were deleted due to low item-adjusted total score correlations. For the six affordability items, a constrained graded response model indicated no items exhibited misfit; thus, all were retained. No items indicated differential item functioning (examined for age, sex, education, race, and socioeconomic status). Thus, the final Affordability item bank comprised six items. A Housing Safety index (three items) and a Home Features index (eight items) were also developed. Reliability (i.e., internal consistency and test-retest reliability) and validity (i.e., convergent, discriminant, and known-groups) of the new measures were also supported. CONCLUSIONS: The REDD-CAT Housing Security Measure provides a reliable and valid assessment of housing affordability, safety, and home features in people with type 2 diabetes mellitus. Future work is needed to establish the clinical utility of this measure in other clinical populations.

Development and calibration data for the Medication Adherence Item Bank: a new computer adaptive test for persons with type 2 diabetes mellitus.

PURPOSE: To develop a new computer adaptive test that evaluates important aspects of medication adherence for persons with type 2 diabetes mellitus. METHODS: Two hundred and twenty-five people with type 2 diabetes mellitus completed 41 items related to medication adherence. RESULTS: Exploratory analysis supported the essential unidimensionality of the initial item pool. Five items were deleted due to low item-adjusted total score correlations (resulting in 36 items). Confirmatory factor analysis supported the retention of 27 items. A graded response model identified no items for exclusion, based on misfit. No items were flagged for meaningful differential item functioning (DIF). The final item bank is comprised of 27 items; an associated 6-item short form was constructed that balanced both psychometric factors (e.g., item information values) and clinical input. Initial analysis of the simulated CAT and static short form supported both the reliability (i.e., internal consistency and test-retest reliability) and validity (i.e., convergent, discriminant, and known groups) of both administration formats. CONCLUSIONS: The new medication adherence item bank provides a reliable and valid assessment of the ability to take medications accurately among people with T2DM; it will be available in early 2023 through healthmeasures.net.

Development and calibration data for the Illness Burden item bank: a new computer adaptive test for persons with type 2 diabetes mellitus.

PURPOSE: The purpose of this study was to develop a new measure, the Re-Engineered Discharge for Diabetes Computer Adaptive Test (REDD-CAT) Illness Burden item bank, to evaluate the impact that a chronic condition has on independent living, the ability to work (including working at home), social activities, and relationships. METHODS: Semi-structured interviews were used to inform the development of an item pool (47 items) that captured patients' beliefs about how a diagnosis of type 2 diabetes interferes with different aspects of their lives. The Illness Burden item bank was developed and tested in 225 people with type 2 diabetes mellitus. RESULTS: No items had sparse response option cells or problems with monotonicity; two items were deleted due to low item-rest correlations. Factor analyses supported the retention of 29 items. With those 29 remaining items, a constrained (common slope) graded response model fit assessment indicated that two items had misfit; they were excluded. No items displayed differential item functioning by age, sex, education, or socio-economic status. The final item bank is comprised of 27 items. Preliminary data supported the reliability (internal consistency and test-retest reliability) and validity (convergent, discriminant, and known-groups) of the new bank. CONCLUSION: The Illness Burden item bank can be administered as a computer adaptive test or a 6-item short form. This new measure captures patients' perceptions of the impact that having type 2 diabetes has on their daily lives; it can be used in conjunction with the REDD-CAT measurement system to evaluate important social determinants of health in persons with type 2 diabetes mellitus.

Development and calibration data for the Healthcare Access Item Bank: a new computer adaptive test for persons with type 2 diabetes mellitus.

PURPOSE: The purpose of this study was to develop a new measure to evaluate the ability to receive medical services when needed among persons with type 2 diabetes mellitus. METHODS: The Healthcare Access measure was developed using data from 225 persons with type 2 diabetes mellitus who completed an item pool comprised of 54 questions pertaining to their experience accessing healthcare services. RESULTS: Exploratory and confirmatory factor analyses supported the retention of 45 items. In addition, a constrained graded response model (GRM), as well as analyses that examined item misfit and differential item functioning (investigated for age, sex, education, race, and socioeconomic status), supported the retention of 44 items in the final item bank. Expert review and GRM item calibration products were used to inform the selection of a 6-item static short form and to program the Healthcare Access computer adaptive test (CAT). Preliminary data supported the reliability (i.e., internal consistency and test-retest reliability) and validity (i.e., convergent, discriminant, and known-groups) of the new measure. CONCLUSIONS: The new Healthcare Access item bank can be used to examine the experiences that persons with type 2 diabetes mellitus have with healthcare access, to better target treatment improvements and mitigate disparities; it will be available as a part of the Neuro-Qol measurement system through healthmeasures.net and the PROMIS Application Programmable Interface (API) in early 2023.

Reducing Readmission of Hospitalized Patients With Depressive Symptoms: A Randomized Trial.

PURPOSE: To determine if hospitalized patients with depressive symptoms will benefit from post-discharge depression treatment with care transition support. METHODS: This is a randomized controlled trial of hospitalized patients with patient health questionnaire-9 score of 10 or more. We delivered the Re-Engineered Discharge (RED) and randomized participants to groups receiving RED-only or RED for Depression (RED-D), a 12-week post-discharge telehealth intervention including cognitive behavioral therapy, self-management support, and patient navigation. Primary outcomes were hospital readmission and reutilization rates at 30 and 90 days post discharge. RESULTS: We randomized 709 participants (353 RED-D, 356 RED-only). At 90 days, 265 (75%) intervention participants had received at least 1 RED-D session (median 4). At 30 days, the intention-to-treat analysis showed no differences between RED-D vs RED-only in hospital readmission (9% vs 10%, incidence rate ratio [IRR] 0.92 [95% CI, 0.56-1.52]) or reutilization (27% vs 24%, IRR 1.14 [95% CI, 0.85-1.54]). The intention-to-treat analysis also showed no differences at 90 days in readmission (28% vs 21%, IRR 1.30 [95% CI, 0.95-1.78]) or reutilization (70% vs 57%, IRR 1.22 [95% CI, 1.01-1.49]). In the as-treated analysis, each additional RED-D session was associated with a decrease in 30- and 90-day readmissions. At 30 days, among 104 participants receiving 3 or more sessions, there were fewer readmissions (3% vs 10%, IRR 0.30 [95% CI, 0.07-0.84]) compared with the control group. At 90 days, among 109 participants receiving 6 or more sessions, there were fewer readmissions (11% vs 21%, IRR 0.52 [95% CI, 0.27-0.92]). Intention-to-treat analysis showed no differences between study groups on secondary outcomes. CONCLUSIONS: Care transition support and post-discharge depression treatment can reduce unplanned hospital use with sufficient uptake of the RED-D intervention.

Interprofessional education in the clinical learning environment: a mixed-methods evaluation of a longitudinal experience in the primary care setting.

Team collaboration in our healthcare workforce is necessary to effectively address multifaceted medical and social needs, especially for those impacted by systemic inequities. Effective interprofessional practice and education models including curricula are needed to prepare a practice ready healthcare workforce for team collaboration. Most healthcare trainee interprofessional experiences take place episodically in classroom settings. However, creating a culture that supports team-based learning and interprofessional clinical practice requires teaching skills (e.g., communication, collaboration, shared decision-making, coordination of care) longitudinally in the clinical setting. A weekly interprofessional clinic for patients/clients with chronic health conditions was organized in three primary care practices. Trainees from nutrition, social work, medicine, and physician assistant programs worked with supervising clinicians from each field. Surveys, interviews, and focus groups assessed the effects of interprofessional education and training in the primary care setting. Results show the longitudinal experiential IPE program significantly improved knowledge, attitudes, skills, and values addressing key interprofessional competencies. Qualitative results complement survey data and highlight key themes addressing patient-centered care and team dynamics. These findings demonstrate the importance of longitudinal, immersive team-based interprofessional training in the clinical learning environment.

Understanding the groups of care transition strategies used by U.S. hospitals: an application of factor analytic and latent class methods.

BACKGROUND: After activation of the Hospital Readmission Reduction Program (HRRP) in 2012, hospitals nationwide experimented broadly with the implementation of Transitional Care (TC) strategies to reduce hospital readmissions. Although numerous evidence-based TC models exist, they are often adapted to local contexts, rendering large-scale evaluation difficult. Little systematic evidence exists about prevailing implementation patterns of TC strategies among hospitals, nor which strategies in which combinations are most effective at improving patient outcomes. We aimed to identify and define combinations of TC strategies, or groups of transitional care activities, implemented among a large and diverse cohort of U.S. hospitals, with the ultimate goal of evaluating their comparative effectiveness. METHODS: We collected implementation data for 13 TC strategies through a nationwide, web-based survey of representatives from short-term acute-care and critical access hospitals (N = 370) and obtained Medicare claims data for patients discharged from participating hospitals. TC strategies were grouped separately through factor analysis and latent class analysis. RESULTS: We observed 348 variations in how hospitals implemented 13 TC strategies, highlighting the diversity of hospitals' TC strategy implementation. Factor analysis resulted in five overlapping groups of TC strategies, including those characterized by 1) medication reconciliation, 2) shared decision making, 3) identifying high risk patients, 4) care plan, and 5) cross-setting information exchange. We determined that the groups suggested by factor analysis results provided a more logical grouping. Further, groups of TC strategies based on factor analysis performed better than the ones based on latent class analysis in detecting differences in 30-day readmission trends. CONCLUSIONS: U.S. hospitals uniquely combine TC strategies in ways that require further evaluation. Factor analysis provides a logical method for grouping such strategies for comparative effectiveness analysis when the groups are dependent. Our findings provide hospitals and health systems 1) information about what groups of TC strategies are commonly being implemented by hospitals, 2) strengths associated with the factor analysis approach for classifying these groups, and ultimately, 3) information upon which comparative effectiveness trials can be designed. Our results further reveal promising targets for comparative effectiveness analyses, including groups incorporating cross-setting information exchange.

Black Men's Experiences With Health care: Individuals' Accounts of Challenges, Suggestions for Change, and the Potential Utility of Virtual Agent Technology to Assist Black Men With Health Management.

Black men have the highest age-adjusted death rate of any major race-gender group in America. Understanding their perceived barriers to accessing health care may benefit future interventions working to increase Black men's health care engagement. Data collected from focus groups of Black men(N = 67), key informant interviews(N = 12), and interviews(N = 5) with participants who pilot tested an online health education system (called "Gabe") were analyzed to explore their health care experiences and how computer-based health programs might better assist Black men. Concerns pertaining to health care systems' failure to recognize the diversity among Black men, and physicians' lack of sociocultural awareness about the challenges they regularly face, were most salient. Building trust with providers was cited as being central to engagement, with Gabe users perceiving the system to be both trustworthy and accessible. Participants reported an openness to technology assisting with health management and provided suggestions of how online systems can meet the needs of Black men.

Study protocol for the implementation of the Gabby Preconception Care System - an evidence-based, health information technology intervention for Black and African American women.

BACKGROUND: Improving the health of women before pregnancy and throughout a woman's lifespan could mitigate disparities and improve the health and wellbeing of women, infants and children. The preconception period is important for reducing health risks associated with poor maternal, perinatal and neonatal outcomes, and eliminating racial and ethnic disparities in maternal and child health. Low cost health information technology interventions provided in community-based settings have the potential to reach and reduce disparities in health outcomes for socially disadvantaged, underserved and health disparity populations. These interventions are particularly important for Black and African American women who have a disproportionate burden of pregnancy-related complications and infant mortality rates compared to any other racial and ethnic group in the U.S. METHODS: This is a hybrid type II implementation-effectiveness cohort study aimed at evaluating appropriateness, acceptability and feasibility implementation outcomes, while also systematically examining the clinical effectiveness of a preconception care (PCC) intervention, the Gabby System, for Black and African American women receiving health services in community-based sites. The intervention will be implemented in six Community Health Centers and six Healthy Start programs across the U.S. Each study site will recruit and enroll 25-50 young Black and African American women who will participate in the intervention for a 6-month period. Appropriateness, acceptability and feasibility of implementing the PCC intervention will be assessed using: 1) Qualitative data derived from individual interviews with Gabby System end-users (clients and patients) and site staff; and, 2) Quantitative data from staff surveys, Gabby System usage and uptake. Aggregate health risk and utilization measures collected directly from the Gabby server will be used to examine the effectiveness of the Gabby System on self-reported behavior change. DISCUSSION: This study will examine implementation outcomes and clinical effectiveness of an evidence-based PCC intervention for Black and African American women receiving services in Healthy Start programs and Community Health Centers. Contextual factors that influence uptake and appropriate implementation strategies will be identified to inform future scalability of the intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT04514224 . Date of registration: August 14, 2020. Retrospectively Registered.

Improving discharge planning using the re-engineered discharge programme.

AIMS: (a) Assess nurses' readiness to learn (RTL) before receiving education on the re-engineered discharge (RED) programme and (b) measure utilization of the RED discharge process from patient chart reviews following an educational intervention. BACKGROUND: Preventable readmissions are of great concern. Rural areas are at a disadvantage, due to decreased access to health care and other disparities. METHODS: Sixty-nine participants completed the Self-Directed Learning Readiness Scale prior to the RED education intervention. Thirty-minute education interventions were provided addressing various learning preferences. RESULTS: Participants scored high M = 219.8 (SD 23.7) on the SDLR, indicating nurses' high RTL prior to educational intervention. Chart reviews found usage of the RED 12 actionable item pre-intervention, (n = 60) M = 6.55 (SD 1.478) compared to post-intervention (n = 60) M = 10.08 (SD 1.544) indicated statistically significant improvement in pre-discharge patient education and planning (t = 17.730, p = 0.000 [CI 3.13-3.93]). CONCLUSION: Current study found that nurses with higher levels of RTL who underwent RED educational sessions significantly improved delivery of the RED process documented in the medical record. IMPLICATIONS FOR NURSING MANAGEMENT: Those responsible for education initiatives must make understanding nurses' learning preferences a priority to improve the quality of bedside practice.

Onset of T2DM after gestational diabetes: What the prevention paradox tells us about risk.

This study investigates the effect of severity of gestational diabetes (GDM) on likelihood of post-delivery glucose testing and early onset Type 2 diabetes (T2DM). We asked if clinical focus on relative risk (RR), i.e. greater probability of T2DM onset in a higher-severity group, contributes to missed opportunities for prevention among women with lower-severity GDM. A sample of 12,622 continuously-insured women with GDM (2006-2015) was drawn from a large national dataset (OptumLabs® Data Warehouse) and followed for 3-years post-delivery. Higher-severity GDM was defined as addition of hypoglycemic therapy to standard of care for GDM. We found that women with higher-severity (n = 2627) were twice as likely as lower-severity women (n = 9995) to obtain glucose testing post-delivery. Moreover, 357 (13.6%) of the higher-severity women developed T2DM by year-3 vs. 600 (6.0%) lower-severity women. In an analysis of the population attributable fraction (PAF), defined as the contribution of excess risk to population prevalence, lower-severity women contributed more cases to diabetes rates than higher-risk women (PAF 79% vs. 21%), despite an increased RR in the higher-severity group (13.6% vs. 6.0%, RR 2.26, 95%CI 2.00, 2.56). Projecting out to the 327,950 U.S. deliveries in 2014, we estimate that 9277 higher-severity women (13.6%) and 15,584 lower-severity women (6.0%), will have developed T2DM by 2018. These data demonstrate that lower-severity GDM contributes substantially to the diabetes epidemic. Greater awareness of clinical and cost implications of gaps in follow-up for lower-severity GDM may strengthen the likelihood of post-delivery testing and primary care referral, and thus reinforce the path to prevention.

Care Transitions From Patient and Caregiver Perspectives.

PURPOSE: Despite concerted actions to streamline care transitions, the journey from hospital to home remains hazardous for patients and caregivers. Remarkably little is known about the patient and caregiver experience during care transitions, the services they need, or the outcomes they value. The aims of this study were to (1) describe patient and caregiver experiences during care transitions and (2) characterize patient and caregiver desired outcomes of care transitions and the health services associated with them. METHODS: We interviewed 138 patients and 110 family caregivers recruited from 6 health networks across the United States. We conducted 34 homogenous focus groups (103 patients, 65 caregivers) and 80 key informant interviews (35 patients, 45 caregivers). Audio recordings were transcribed and analyzed using principles of grounded theory to identify themes and the relationship between them. RESULTS: Patients and caregivers identified 3 desired outcomes of care transition services: (1) to feel cared for and cared about by medical providers, (2) to have unambiguous accountability from the health care system, and (3) to feel prepared and capable of implementing care plans. Five care transition services or provider behaviors were linked to achieving these outcomes: (1) using empathic language and gestures, (2) anticipating the patient's needs to support self-care at home, (3) collaborative discharge planning, (4) providing actionable information, and (5) providing uninterrupted care with minimal handoffs. CONCLUSIONS: Clear accountability, care continuity, and caring attitudes across the care continuum are important outcomes for patients and caregivers. When these outcomes are achieved, care is perceived as excellent and trustworthy. Otherwise, the care transition is experienced as transactional and unsafe, and leaves patients and caregivers feeling abandoned by the health care system.

Project ACHIEVE - using implementation research to guide the evaluation of transitional care effectiveness.

BACKGROUND: Poorly managed hospital discharges and care transitions between health care facilities can cause poor outcomes for both patients and their caregivers. Unfortunately, the usual approach to health care delivery does not support continuity and coordination across the settings of hospital, doctors' offices, home or nursing homes. Though complex efforts with multiple components can improve patient outcomes and reduce 30-day readmissions, research has not identified which components are necessary. Also we do not know how delivery of core components may need to be adjusted based on patient, caregiver, setting or characteristics of the community, or how system redesign can be accelerated. METHODS/DESIGN: Project ACHIEVE focuses on diverse Medicare populations such as individuals with multiple chronic diseases, patients with low health literacy/numeracy and limited English proficiency, racial and ethnic minority groups, low-income groups, residents of rural areas, and individuals with disabilities. During the first phase, we will use focus groups to identify the transitional care outcomes and components that matter most to patients and caregivers to inform development and validation of assessment instruments. During the second phase, we will evaluate the comparative effectiveness of multi-component care transitions programs occurring across the U.S. Using a mixed-methods approach for this evaluation, we will study historical (retrospective) and current and future (prospective) groups of patients, caregivers and providers using site visits, surveys, and clinical and claims data. In this natural experiment observational study, we use a fractional factorial study design to specify comparators and estimate the individual and combined effects of key transitional care components. DISCUSSION: Our study will determine which evidence-based transitional care components and/or clusters most effectively produce patient and caregiver desired outcomes overall and among diverse patient and caregiver populations in different healthcare settings. Using the results, we will develop concrete, actionable recommendations regarding how best to implement these strategies. Finally, this work will provide tools for hospitals, community-based organizations, patients, caregivers, clinicians and other stakeholders to help them make informed decisions about which strategies are most effective and how best to implement them in their communities. TRIAL REGISTRATION: Registered as NCT02354482 on clinicaltrials.gov on 1/29/2015.

Evidence-based preconceptional lifestyle interventions.

Although the evidence for the associations between preconceptional risk factors and adverse pregnancy outcomes is extensive, the effectiveness of preconceptional interventions to reduce risk factors and to improve pregnancy outcomes remains partly unclear. The objective of this review is to summarize the available effectiveness of lifestyle interventions prior to pregnancy for women in terms of behavior change and pregnancy outcome. A predefined search strategy was applied in electronic databases, and citation tracking was performed. Study selection was performed by 2 independent reviewers according to predefined criteria for eligibility: The intervention was performed preconceptionally on women regarding alcohol use, smoking, weight, diet/nutrition, physical activity, and folic acid status (fortification and supplementation) to achieve behavior change and/or improve pregnancy outcome. Quality and strength of evidence were assessed by 2 independent reviewers. A total of 4,604 potentially relevant records were identified, of which 44 records met the inclusion criteria. Overall, there is a relatively short list of core interventions for which there is substantial evidence of effectiveness when applied in the preconception period.

Patient activation and 30-day post-discharge hospital utilization.

BACKGROUND: Patient activation is linked to better health outcomes and lower rates of health service utilization. The role of patient activation in the rate of hospital readmission within 30 days of hospital discharge has not been examined. METHODS: A secondary analysis using data from the Project RED-LIT randomized controlled trial conducted at an urban safety net hospital. Data from 695 English-speaking general medical inpatient subjects were analyzed. We used an adapted, eight-item version of the validated Patient Activation Measure (PAM). Total scores were categorized, according to standardized methods, as one of four PAM levels of activation: Level 1 (lowest activation) through Level 4 (highest activation). The primary outcome measure was total 30-day post-discharge hospital utilization, defined as total emergency department (ED) visits plus hospital readmissions including observation stays. Poisson regression was used to control for confounding. RESULTS: Of the 695 subjects, 67 (9.6 %) were PAM Level 1, 123 (17.7 %) were Level 2, 193 (27.8 %) were Level 3, and 312 (44.9 %) were Level 4. Compared with highly activated patients (PAM Level 4), a higher rate of 30-day post-discharge hospital utilization was observed for patients at lower levels of activation (PAM Level 1, incident rate ratio [IRR] 1.75, 95 % CI,1.18 to 2.60) and (PAM Level 2, IRR 1.50, 95 % CI 1.06 to 2.13). The rate of returning to the hospital among patients at PAM Level 3 was not statistically different than patients with PAM Level 4 (IRR 1.30, 95 % CI, 0.94 to 1.80). The rate ratio for PAM Level 1 was also higher compared with Level 4 for ED use alone (1.68(1.07 to 2.63)) and for hospital readmissions alone (1.93 [1.22 to 3.06]). CONCLUSION: Hospitalized adult medical patients in an urban academic safety net hospital with lower levels of Patient Activation had a higher rate of post-discharge 30-day hospital utilization.

Developing a hospital quality improvement initiative in Lesotho.

PURPOSE: Hospital-based quality improvement (QI) programs are becoming increasingly common in developing countries as a sustainable method of strengthening health systems. The aim of this paper is to present the results and lessons learned from a QI program in a large, rural, district hospital in Lesotho, Southern Africa. DESIGN/METHODOLOGY/APPROACH: Over a 15-month period, a locally-relevant, hospital-wide QI program was developed and implemented. The QI program consisted of: planning meetings with district and hospitals staff; creation of multi-disciplinary QI teams; establishment of a QI steering committee; design and implementation of a locally appropriate QI curriculum; and monthly consultation from technical advisers. Initial QI programming was developed in three distinct areas: maternity care, out-patient care, and referral systems. FINDINGS: Partogram documentation in the maternity department increased by 78 percent, waiting time for critically ill patients in the out-patient department was reduced by 84 percent, and emergency referral times were reduced by 58 percent. ORIGINALITY/VALUE: The design and early implementation of QI programs should focus on easily achievable, locally-relevant improvement projects. It was found that early successes helped to fuel further QI gains and the authors believe that the work building sustainable QI skill sets within hospital staff could be useful in the future when attempting to tackle larger national-level quality of care indicators. The findings add to the existing evidence suggesting that an increased use of locally-relevant quality improvement programming could help strengthen health care systems in low resource settings.

Usability and Acceptability of a Conversational Agent Health Education App (Nthabi) for Young Women in Lesotho: Quantitative Study.

BACKGROUND: Young women in Lesotho face myriad sexual and reproductive health problems. There is little time to provide health education to women in low-resource settings with critical shortages of human resources for health. OBJECTIVE: This study aims to determine the acceptability and usability of a conversational agent system, the Nthabi health promotion app, which was culturally adapted for use in Lesotho. METHODS: We conducted a descriptive quantitative study, using a 22-item Likert scale survey to assess the perceptions of the usability and acceptability of 172 young women aged 18-28 years in rural districts of Lesotho, who used the system on either smartphones or tablets for up to 6 weeks. Descriptive statistics were used to calculate the averages and frequencies of the variables. χ2 tests were used to determine any associations among variables. RESULTS: A total of 138 participants were enrolled and completed the survey. The mean age was 22 years, most were unmarried, 56 (40.6%) participants had completed high school, 39 (28.3%) participants were unemployed, and 88 (63.8%) participants were students. Respondents believed the app was helpful, with 134 (97.1%) participants strongly agreeing or agreeing that the app was "effective in helping them make decisions" and "could quickly improve health education and counselling." In addition, 136 (98.5%) participants strongly agreed or agreed that the app was "simple to use," 130 (94.2 %) participants reported that Nthabi could "easily repeat words that were not well understood," and 128 (92.7%) participants reported that the app "could quickly load the information on the screen." Respondents were generally satisfied with the app, with 132 (95.6%) participants strongly agreeing or agreeing that the health education content delivered by the app was "well organised and delivered in a timely way," while 133 (96.4%) participants "enjoyed using the interface." They were satisfied with the cultural adaptation, with 133 (96.4%) participants strongly agreeing or agreeing that the app was "culturally appropriate and that it could be easily shared with a family or community members." They also reported that Nthabi was worthwhile, with 127 (92%) participants reporting that they strongly agreed or agreed that they were "satisfied with the application and intended to continue using it," while 135 (97.8%) participants would "encourage others to use it." Participants aged 18-24 years (vs those aged 25-28 years) agreed that the "Nthabi app was simple to use" (106/106, 100% vs 30/32, 98.8%; P=.01), and agreed that "the educational content was well organised and delivered in a timely way" (104/106, 98.1% vs 28/32, 87.5%; P=.01). CONCLUSIONS: These results support further study of conversational agent systems as alternatives to traditional face-to-face provision of health education services in Lesotho, where there are critical shortages of human resources for health. TRIAL REGISTRATION: ClinicalTrials.gov NCT04354168; https://www.clinicaltrials.gov/study/NCT04354168.

Psychological distress and PTSD among clinicians in Roma, Lesotho during the COVID-19 pandemic.

BACKGROUND:  Since 2020, the world has been battling the coronavirus disease 2019 (COVID-19) pandemic. The mortality and morbidity at the height of the pandemic sparked generalised fear and uncertainty about the future. Concerns were raised about the psychological impact of the pandemic on workers in healthcare systems globally. This study was conducted to establish the degree of psychological impact of the pandemic on frontline health workers in Lesotho. METHODS:  The study used a quantitative cross-sectional survey design. The Kessler psychological distress screening tool (K-10) and the post-traumatic stress disorder (PTSD) checklist for civilians (PCL-C) were administered to screen for psychological distress among clinical staff at St. Joseph's Hospital in Roma and its four Health Centres. Additional open- and closed-ended questions were added for context. Data were analysed using Fisher's exact tests, Pearson chi-square tests and correlation studies. RESULTS:  Of the 101 participants, 42 (41.6%) scored ≥ 24 on the K-10 scale (95% CI: 32.0% - 51.2%) indicating moderate to severe psychological distress and 32 (31.7%) scored ≥ 50 on the PCL-C checklist suggesting severe PTSD (95% CI: 24.5% - 42.9%). High scores on the K-10 were found more among men than women (17 [37.8%] vs. 4 [7.1%]; p ≤ 0.001). Post-traumatic stress disorder was more in the younger age group (p ≤ 0.03), in those reporting anxiety (p = 0.005) and those with more co-morbidities (p ≤ 0.001). CONCLUSION:  This study revealed the grave psychological impact of the COVID-19 pandemic on frontline clinical health workers in Lesotho.Contribution: These data will assist health leaders and policymakers to implement mental health support interventions for health workers in future.

Learning from the End of the Public-Private Partnership for Lesotho's National Referral Hospital Network.

Background: Public-private partnerships (PPP) are one strategy to finance and deliver healthcare in lower-resourced settings. Lesotho's Queen 'Mamohato Memorial Hospital Integrated Network (QMMH-IN) was sub-Saharan Africa's first and largest integrated healthcare PPP. Objective: We assessed successes and challenges to performance of the QMMH-IN PPP. Methods: We conducted 26 semi-structured interviews among QMMH-IN executive leadership and staff in early 2020. Questions were guided by the WHO Health System Building Blocks Framework. We conducted a thematic analysis. Findings: Facilitators of performance included: 1) PPP leadership commitment to quality improvement supported by protocols, monitoring, and actions; 2) high levels of accountability and discipline; and 3) well-functioning infrastructure, core systems, workflows, and internal referral network. Barriers to performance included: 1) human resource management challenges and 2) broader health system and referral network limitations. Respondents anticipated the collapse of the PPP and suggested better investing in training incoming managerial staff, improving staffing, and expanding QMMH-IN's role as a training facility. Conclusions: The PPP contract was terminated approximately five years before its anticipated end date; in mid-2021 the government of Lesotho assumed management of QMMH-IN. Going forward, the Lesotho government and others making strategic planning decisions should consider fostering a culture of quality improvement and accountability; ensuring sustained investments in human resource management; and allocating resources in a way that recognizes the interdependency of healthcare facilities and overall system strengthening. Contracts for integrated healthcare PPPs should be flexible to respond to changing external conditions and include provisions to invest in people as substantively as infrastructure, equipment, and core systems over the full length of the PPP. Healthcare PPPs, especially in lower-resource settings, should be developed with a strong understanding of their role in the broader health system and be implemented in conjunction with efforts to ensure and sustain adequate capacity and resources throughout the health system.

Health literacy and complementary and alternative medicine use among underserved inpatients in a safety net hospital.

Little is known about the relationship between health literacy and complementary and alternative medicine (CAM) use in low-income racially diverse patients. The authors conducted a secondary analysis of baseline data from 581 participants enrolled in the Re-Engineered Discharge clinical trial. The authors assessed sociodemographic characteristics, CAM use, and health literacy. They used bivariate and multivariate logistic regression to test the association of health literacy with four patterns of CAM use. Of the 581 participants, 50% reported using any CAM, 28% used provider-delivered CAM therapies, 27% used relaxation techniques, and 21% used herbal medicine. Of those with higher health literacy, 55% used CAM. Although there was no association between health literacy and CAM use for non-Hispanic Black participants, non-Hispanic White (OR = 3.68, 95% CI [1.27, 9.99]) and Hispanic/other race (OR = 3.40, 95% CI [1.46, 7.91]) participants were significantly more likely to use CAM if they had higher health literacy. For each racial/ethnic group, there were higher odds of using relaxation techniques among those with higher health literacy. Underserved hospitalized patients use CAM. Regardless of race, patients with high health literacy make greater use of relaxation techniques.