A Process Evaluation of a Palliative Care Social Work Intervention for Cancer Patients in Skilled Nursing Facilities.

Background: Assessing and Listening to Individual Goals and Needs (ALIGN) is a palliative care social work intervention that aims to improve delivery of goal-concordant care for hospitalized older adults with cancer discharged to skilled nursing facilities. Objective: Explore processes through which ALIGN may improve delivery of goal-concordant care to substantiate the conceptual model grounding the intervention and to inform mechanistic hypotheses of how the intervention might be effective. Design: A process evaluation triangulating findings from patient and caregiver interviews with a matrix analysis of ALIGN social worker notes. Setting/Participants: Patients (n = 6) and caregivers (n = 13) who participated in a single-arm pilot study of ALIGN in the United States and 113 intervention notes (n = 18 patients) written by 2 ALIGN social workers. Measurement: Qualitative thematic content analysis Results: Themes included the following: (1) ALIGN helped reconcile participants' misaligned expectations of rehabilitation with the reality of the patient's progressive illness; (2) ALIGN helped participants manage uncertainty and stress about forthcoming medical decision making; (3) the longitudinal nature of ALIGN allowed for iterative value-based goals of care discussions during a time when patients were changing their focus of treatment; and (4) ALIGN activated participants to advocate for their needs. Conclusions: ALIGN offers support in prognostic understanding, communication, and decision making during a pivotal time when patient and caregivers' goals have not been met and they are reassessing priorities. A larger trial is needed to understand how these processes may improve the ability of participants to make value-based decisions and aide in delivery of goal-concordant care. Clinical Trial Registration Number: NCT04882111.

Provider perspectives and recommendations on standardized sexual function screening intervention in adolescent/young adult oncology patients.

BACKGROUND: Sexual function (SF) concerns are common among adolescent and young adult (AYA) cancer survivors, are underrecognized and undertreated. This study sought AYA oncology provider input on the implementation of an SF screening tool to address this unmet need. PROCEDURE: Semi-structured interviews were completed with oncology providers (n = 25) who care for AYAs at a single institution. Interviews sought to understand barriers to addressing SF, elicit perspectives on use of an established screening tool, and obtain recommendations for SF screening intervention development and implementation. Interviews were developed using the Consolidated Framework for Implementation Research (CFIR); thematic analysis-guided interpretation. RESULTS: AYA oncology providers were in favor of using an SF screening tool, but confirmed previously identified barriers and implementation considerations within multiple CFIR domains, including concerns about privacy, patient comfort, provider buy-in, provider knowledge, resource needs, and workflow/capacity constraints. They identified numerous strategies to address barriers through screening intervention design and implementation approaches. For example, provider buy-in could be optimized through education, availability of clinical resources, creation of a dedicated sexual healthcare team, provider engagement in intervention development, and leadership involvement. CONCLUSIONS: Development and implementation of an effective SF screening intervention is necessary to improve diagnosis and treatment of sexual dysfunction, with the ultimate goal of improving sexual health-related quality of life in AYA cancer survivors. AYA oncology providers identified numerous intervention and implementation design strategies for the development and implementation of an SF screening intervention, which must be integrated with patient recommendations.

Clinical decision support tools for paediatric sepsis in resource-poor settings: an international qualitative study.

OBJECTIVE: New paediatric sepsis criteria are being developed by an international task force. However, it remains unknown what type of clinical decision support (CDS) tools will be most useful for dissemination of those criteria in resource-poor settings. We sought to design effective CDS tools by identifying the paediatric sepsis-related decisional needs of multidisciplinary clinicians and health system administrators in resource-poor settings. DESIGN: Semistructured qualitative focus groups and interviews with 35 clinicians (8 nurses, 27 physicians) and 5 administrators at health systems that regularly provide care for children with sepsis, April-May 2022. SETTING: Health systems in Africa, Asia and Latin America, where sepsis has a large impact on child health and healthcare resources may be limited. PARTICIPANTS: Participants had a mean age of 45 years, a mean of 15 years of experience, and were 45% female. RESULTS: Emergent themes were related to the decisional needs of clinicians caring for children with sepsis and to the needs of health system administrators as they make decisions about which CDS tools to implement. Themes included variation across regions and institutions in infectious aetiologies of sepsis and available clinical resources, the need for CDS tools to be flexible and customisable in order for implementation to be successful, and proposed features and format of an ideal paediatric sepsis CDS tool. CONCLUSION: Findings from this study will directly contribute to the design and implementation of CDS tools to increase the uptake and impact of the new paediatric sepsis criteria in resource-poor settings.

Disability doesn't discriminate: health inequities at the intersection of race and disability.

Objectives: Given the prevalence of discrimination experienced by racial and ethnic minorities living with disabilities, it is likely that racism experienced by Black, Indigenous, and people of color (BIPOC) is compounded by the ableism experienced by people with disabilities, widening disparities in health and healthcare outcomes. To address this, we described unmet healthcare needs of a sample of Black, non-Hispanic, and Hispanic adults with and without disabilities. The following research question was examined exploratively: Are Black and Hispanic adults with disabilities at increased risk of unmet healthcare needs compared to Black and Hispanic adults without disabilities according to the 2018 National Health Interview Survey? Methods: Survey data was examined from the 2018 National Health Interview Survey (NHIS), a nationally representative survey of community-dwelling adults in the United States. Results: Black and non-Hispanic adults most commonly reported mobility only disabilities. People with disabilities were significantly more likely to delay or forego care than their peers without disabilities within each racial/ethnic group. Among non-Hispanic Black and Hispanic adults, nearly 30% of people with disabilities forewent services due to cost compared to persons without disabilities. Conclusions: Black and Hispanic adults with disabilities experience greater disparities in access to healthcare than Black and Hispanic adults without disabilities. Therefore, health disparities experienced by racial and ethnic minorities living with disabilities is likely influenced by the dual systemic factors of racism and ableism.

Pilot Trial of a Social Work Intervention to Provide Palliative Care for Adults with Cancer in Skilled Nursing Facilities.

Background: Hospitalized patients with cancer and their caregivers discharged to skilled nursing facilities (SNFs) have unmet palliative care needs. Objective: To determine feasibility and acceptability of Assessing and Listening to Individual Goals and Needs (ALIGN), a palliative care social worker (PCSW) intervention, for older adults and their caregivers in SNFs. Design: Single-arm, single-site pilot study. Predefined feasibility goals were >70% intervention completion and study retention rates (postintervention outcomes completed at one week). Setting/Subjects: Twenty-three patients with cancer and their 21 caregivers discharged to 12 SNFs posthospitalization. Measurements: Primary outcomes were feasibility and acceptability. Exploratory patient and caregiver-reported outcomes, including goals of care were collected at baseline and one week postintervention. Health care utilization, mortality, and hospice utilization was collected at the six-month follow-up. Results: Of 73 patients screened, 35 (48%) were eligible and 23 (66%) patients and 21 caregivers enrolled. Eighteen (78%) patients completed the intervention and 10 (44%) patients and 13 (62%) caregivers provided follow-up outcomes. Average age of patients was 73, and 19 (83%) had stage III or IV cancer. Average age of caregivers was 55. Eight (44%) patients' preferences changed to prefer less aggressive care. Nineteen (83%) patients died during or shortly after intervention completion. Qualitative feedback from participant and SNF staff interviews supported high acceptability. PCSW involvement increased illness understanding and patient engagement with advance care planning. SNF staff valued increased palliative support. Conclusions: Intervention completion was >70%, however, not study retention due to higher-than-expected mortality. Future study should account for high mortality and examine whether ALIGN can better prepare surrogate decision makers and enhance the ability of SNFs to address changing goals of care. Clinical Trial Registration Number NCT04882111.

How Do Patients Describe Hospice Care? A Qualitative Analysis of the Language Used by Older Adults to Describe Hospice Care.

Background: Misconceptions about hospice are prevalent and create barriers to hospice enrollment. These misconceptions may be a result of the confusing language around hospice care. Objective: To conduct a content analysis exploring the language used and accuracy in which older adults describe hospice. Design: Participants in two prior studies were asked to describe hospice in their own words. Responses were coded inductively to explore the language used, and deductively to evaluate accuracy in describing hospice. Subjects: Two hundred sixty-six adults, aged at least 65 years or older. Results: The most common language used to describe hospice care related to "comfort," "care," and "family." Most participants accurately describe hospice eligibility, services, and goals of care but inaccurately described location of hospices services. Conclusions: Participants accurately described most of the logistical aspects of hospice care and words such as comfort, care, and family are commonly used to describe services suggesting preferred language for communication interventions. Clinicaltrials.gov (Cohort #1 NCT03794700 and Cohort #2 NCT04458090).

"These Are Our Kids": Qualitative Interviews With Clinical Leaders in General Emergency Departments on Motivations, Processes, and Guidelines in Pediatric Sepsis Care.

STUDY OBJECTIVE: Sepsis is a leading cause of pediatric death requiring emergency resuscitation. Most children with sepsis are treated in general emergency departments (EDs); however, research has focused on pediatric EDs. We sought to identify barriers and facilitators to pediatric sepsis care in general EDs, including care processes, the role of guidelines, and incentivized metrics. METHODS: In this qualitative study, we conducted semistructured interviews with key informant physician and nurse leaders overseeing pediatric sepsis in general EDs in 2021, including medical directors, nurse managers, and quality coordinators. Interviews were audio-recorded, transcribed, and coded using deductive domains based on steps of sepsis care, pediatric readiness, and structural dynamics. Domains were analyzed across interviews in matrices, using thematic analysis within domains. RESULTS: Twenty-one clinical leaders representing 26 hospitals, including trauma levels I to IV, were interviewed. The themes included the following: (1) motivation to improve pediatric sepsis care based on moral imperative and location; (2) need for actionable pediatric sepsis guidelines; (3) children's hospitals' role in education, protocols, transfer, and consultation; and (4) mixed feelings about reportable metrics, particularly in EDs with low pediatric volume. Sepsis care process challenges included diagnosis, intravenous access, and antibiotic delivery but varied among hospitals. CONCLUSION: Leaders in general EDs were motivated to provide high-quality pediatric sepsis care but disagreed on whether reportable metrics would drive improvements. They universally sought direct support from their nearest children's hospitals and actionable guidelines. Efforts to address pediatric sepsis quality in general EDs should prioritize guideline design, responsive pediatric transfer and consultation systems, and locally specific process improvement.

A mobile cesarean birth center as a solution to improve access to surgical birth in rural Ethiopia: a mixed methods research protocol.

BACKGROUND: As an evidence-based intervention to prevent maternal and neonatal morbidity and mortality, cesarean birth at rates of under 2%, which is the case in rural Southwest Ethiopia, is an unacceptable public health problem and represents an important disparity in the use of this life-saving treatment compared to more developed regions. The objective of this study is to explore an innovative clinical solution (a mobile cesarean birth center) to low cesarean birth rates resulting from the Three Delays to emergency obstetric care in isolated and underserved regions of Ethiopia, and the world. METHODS: We will use mixed but primarily qualitative methods to explore and prepare the mobile cesarean birth center for subsequent implementation in communities in Bench Sheko and West Omo Zones. This will involve interviews and focus groups with key stakeholders and retreat settings for user-centered design activities. We will present stakeholders with a prototype surgical truck that will help them conceive of the cesarean birth center concept and discuss implementation issues related to staffing, supplies, referral patterns, pre- and post-operative care, and relationship to locations for vaginal birth. DISCUSSION: Completion of our study aims will allow us to describe participants' perceptions about barriers and facilitators to cesarean birth and their attitudes regarding the appropriateness, acceptability, and feasibility of a mobile cesarean birth center as a solution. It will also result in a specific, measurable, attainable, relevant, and timely (SMART) implementation blueprint(s), with implementation strategies defined, as well as recruitment plans identified. This will include the development of a logic model and process map, a timeline for implementation with strategies selected that will guide implementation, and additional adaptation/adjustment of the mobile center to ensure fit for the communities of interest. TRIAL REGISTRATION: There is no healthcare intervention on human participants occurring as part of this research, so the study has not been registered.

Adolescent and young adult childhood cancer survivors' preferences for screening and education of sexual function.

BACKGROUND: Sexual dysfunction (SD) is a common yet underrecognized concern among childhood cancer survivors (CCS). CCS who are now adolescent and young adult (AYA-CCS) identify SD as an unmet need. This study sought to explore AYA-CCS preferences on how, when, where, and by whom SD-focused communication should occur. PROCEDURE: This qualitative study utilized semi-structured interviews to explore AYA-CCS (now aged 15-24 years) experiences with, and preferences for, SD conversations. Thematic analysis methodology guided interpretation; themes were clustered into categories of who, how, when, and where SD conversations should occur. RESULTS: AYA-CCS highlighted the importance of patient-provider rapport to facilitate SD conversations, but did not have consistent preferences regarding provider type or specialty. Providers should reduce discomfort by normalizing ongoing, personalized conversations. Some AYA-CCS mentioned that notification that such a conversation is going to occur would be appreciated, and most were in favor of a screening tool to facilitate conversations. Preferences for when and where SD conversations should occur were centered on maximizing privacy. CONCLUSIONS: SD is an inadequately addressed concern in AYA-CCS, and providers must familiarize themselves with AYA-CCS preferences for discussing SD to reduce communication barriers and address this unmet need. In addition to corroborating prior studies' findings such as normalizing ongoing SD conversations, this study demonstrated novel ideas for reducing barriers, including use of a notification to prepare them prior to SD conversations, favoring the use of a screening tool, and the importance of establishing rapport prior to the SD conversations.

Veteran peer suicide prevention: A community-based peer prevention model.

OBJECTIVE: The purpose of this study was to develop a conceptual model of community-based veteran peer suicide prevention. METHOD: We conducted a qualitative study in which semi-structured interviews were followed by three focus groups. Participants (n = 17) were chosen from community-based organizations who had peers working on veteran suicide prevention; the sample included veteran peers, non-peers, program managers, and community stakeholders. Interview data were analyzed thematically and inductively to identify key components and subcomponents of veteran peer suicide prevention. A draft model was shared with each focus group to elicit feedback and refine key concepts. RESULTS: A conceptual model containing nine components and twenty-six subcomponents was developed. Participants emphasized key organizational, relational, and practical elements needed to achieve positive outcomes. In addition, they described critical contextual and cultural factors that impacted veteran peers' ability to prevent suicide and promote overall wellness. CONCLUSIONS: Community-based veteran peer efforts are a promising public health approach to preventing veteran suicide. Provided veteran peers are supported and fully allowed to contribute, these efforts can complement existing clinic-based efforts. Future research on community-based veteran peer suicide prevention should document a range of outcomes (e.g., clinical, wellness, financial) and allow for considerable flexibility in peer approaches.

Perspectives of Patients with Diverse Disabilities Regarding Healthcare Accommodations to Promote Healthcare Equity: a Qualitative Study.

BACKGROUND: Patients with disabilities often require healthcare accommodations in order to access high-quality, equitable healthcare services. While attention has been paid to accommodation needs in specific disability populations, limited research to date has explored healthcare accommodations that cross-cut diverse disability populations. OBJECTIVE: To identify a deeper understanding regarding accommodations in healthcare settings that could apply across disability populations and promote equitable healthcare. DESIGN: We conducted qualitative focus groups with patients with disabilities and caregivers to understand their experiences and preferences for healthcare accommodations. PARTICIPANTS: We recruited patients and caregivers across all major disability categories to participate in focus groups. Participants were recruited through advocacy organizations and healthcare settings in Southeastern Minnesota. APPROACH: A total of eight focus groups were conducted with 56 participants. Participants described their healthcare experiences and desires for healthcare accommodations. The multidisciplinary research team recorded, transcribed verbatim, and coded all focus groups. The team thematically coded transcripts using content analysis within and across focus groups to identify major themes. KEY RESULTS: Patients identified four challenges and corresponding steps healthcare team could take to promote equitable care: (1) consistent documentation of disabilities and needed accommodations in the medical record; (2) allowance for accommodations to the environment, including adapting physical space, physical structures, and scheduling and rooming processes; (3) provide accommodations for administrative tasks, such as completing paper or electronic forms; and (4) adapt communication during interactions, such as speaking slower or using terms that patients can easily understand. CONCLUSION: These identified themes represent specific opportunities for healthcare teams to effectively provide accessible care to patients with disabilities. Many of the accommodations require minimal financial investment, but did require behavioral changes by the healthcare team to ensure equitable healthcare.

Evaluation of the v2.0 Brief Profiles for Sexual Function and Satisfaction PROMIS in Adolescent and Young Adult Childhood Cancer Survivors.

Purpose: Sexual dysfunction (SD) is a common, but often unrecognized potential late effect among childhood cancer survivors (CCS). Unfortunately, both patients and providers report low levels of routine screening and identify multiple barriers, including lack of knowledge, discomfort, and limited time. This is particularly true among CCS who are adolescent or young adult aged (AYA-CCS). One potential way to increase screening, detection, and treatment for SD among AYA-CCS is to employ patient-reported outcomes measures. While adult screening tools exist, no SD screening tool has been evaluated specifically among this younger population. Methods: This qualitative study used Think-Aloud and cognitive interviewing methods to obtain feedback from AYA-CCS on acceptability, usefulness, and validity of the Patient-Reported Outcomes Measurement Information System® (PROMIS®) v2.0 Brief Profiles for Sexual Function and Satisfaction (SexFS Brief) in CCS now 15-24 years of age. Results: The SexFS Brief demonstrated acceptability, response process and content validity, and usefulness among AYA-CCS. There were no detectable differences by age or gender. This study did not reveal any necessary modification to the SexFS Brief for this population. Conclusion: The PROMIS SexFS Brief is an acceptable and useful tool, with demonstrated response process and content validity, and may facilitate improved screening and diagnosis of SD among AYA-CCS. Furthermore, this tool was viewed favorably by AYA-CCS as a way to reduce barriers such as discomfort and lack of knowledge on the part of patients. Further evaluation of its effectiveness and acceptability in a clinical setting is warranted.

Understanding female veterans' experiences and perspectives of firearms.

OBJECTIVES: Although firearms are the leading suicide means among female veterans, firearm research in this population remains limited. This study explored female veterans' firearm-related experiences and perspectives. METHOD: Sixteen cisgender female veterans (ages 27-69) participated in qualitative interviews. RESULTS: Participants gained initial firearm knowledge and exposure in childhood and adolescence through older male family members. Military service led to broader exposure to firearms, which were perceived as important for survival and protection in a male-dominated environment, predominantly due to the risk for sexual violence. Following military service, the desire for self-protection motivated firearm ownership and storage practices. Participants perceived trust as essential to firearm discussions, preferring for family members to initiate such conversations. CONCLUSIONS: This study provides insight into the context in which female veterans' firearm-related beliefs and practices develop. Interpersonal factors and various lifespan experiences appear to play a vital role in female veterans' firearm access, ownership, and storage practices.

Correction: Firearm-related experiences and perceptions among United States male veterans: A qualitative interview study.

[This corrects the article DOI: 10.1371/journal.pone.0230135.].

Firearm-related experiences and perceptions among United States male veterans: A qualitative interview study.

BACKGROUND/OBJECTIVE: Male veterans ages 55-74 comprise a disproportionate number of suicide deaths among United States veterans, for whom a majority of suicides are firearm-related. Little is known about the firearm-related experiences and beliefs of veterans, which could be informative for firearm-related lethal means safety interventions. The aim of this qualitative study was to identify themes relevant to developing such interventions among older male veterans. METHODS: We conducted semi-structured qualitative interviews with seventeen United States male veterans, ages 50-70, who were eligible to receive Veterans Health Administration services, and were current or former firearm owners or users. Transcripts were analyzed via thematic analysis using an inductive approach. RESULTS: Six themes were identified: 1) Firearm experiences were usually facilitated by male family members and occurred at an early age; 2) Safety lessons during early firearm encounters focused on preventing unintentional injuries through safe firearm handling and using "common sense;" 3) Firearms serve an important social function across veterans' lifespans (e.g., hunting with friends); 4) Veterans perceive firearms as useful for protection; 5) Veterans believe that not everyone should have access to firearms, and some described scenarios in which they acted to limit others' access during unsafe situations; and 6) Veterans have preferences for who is involved in firearm safety discussions. CONCLUSIONS: We identified themes relevant to developing firearm-specific lethal means safety interventions among older male veterans. Findings suggest potential obstacles (e.g., sociocultural value of firearms) to affecting changes in firearm behaviors, and factors that could potentially facilitate interventions (e.g., family involvement). Consideration of these findings may be important for developing personalized, effective interventions for this population.

"We're Afraid to Say Suicide": Stigma as a Barrier to Implementing a Community-Based Suicide Prevention Program for Rural Veterans.

Suicide is a significant public health concern for veterans residing in rural communities. Although various initiatives have been implemented to prevent suicide among veterans, efforts specific to rural veterans remain limited. To aid such efforts, we examined stigma as a potential barrier to community readiness in the implementation of a community-based suicide prevention program for rural veterans. In this qualitative study, community readiness interviews were conducted with 13 participants in a rural community. Themes included lack of awareness regarding veteran suicide, rare discussions of veteran suicide, and suicide-related stigma within the community. Results suggest that prioritizing destigmatization may be particularly important to implementing community-based suicide prevention programming in rural communities. In particular, addressing community misconceptions regarding veteran suicide, while increasing knowledge of the extent to which veteran suicide occurs locally may facilitate increased awareness and thus community readiness to prevent suicide among rural veterans.

Military sexual trauma survivors' perceptions of veterans health administration care: A qualitative examination.

Although the Veterans Health Administration (VHA) provides free health care related to military sexual trauma (MST), many veterans forgo or delay such care, underscoring the need for research aimed at understanding MST survivors' perceptions and concerns regarding VHA care. This study employed a qualitative phenomenological approach to describe MST survivors': (a) perceptions of VHA care, (b) concerns about VHA care, and (c) suggestions for how VHA can facilitate recovery from MST. Fifty veterans (32 women, 18 men) with histories of MST participated in semistructured interviews. Transcripts were analyzed using thematic analysis. The pattern of themes was examined by gender and MST type. The majority of participants described neutral or positive perceptions of VHA care; however, a subset of participants described negative perceptions and reservations about using VHA care. Participants expressed concerns regarding distrust, provider compassion, privacy, stigma, shame, and continuity of care. Some women, particularly those who experienced military sexual assault, also described gender-related distress (e.g., feeling anxious or out of place, desire for separate facilities). Both men and women described wanting nonspecific support, improved continuity of care, and the ability to choose from a variety of treatment options (e.g., holistic, gender-specific). Further research is needed to examine if these findings are replicated in other samples. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Executive functioning and suicidal behavior among veterans with and without a history of traumatic brain injury.

OBJECTIVE: To examine the relationship between executive dysfunction, as a multidimensional construct (ie, decision-making, impulsivity, aggression, concept formation), and suicide attempt (SA) history in a high-risk sample of veterans with moderate to severe traumatic brain injury (TBI). DESIGN: Observational, 2×2 factorial design. To estimate group differences, linear regression was used to model the primary and secondary outcomes of interest as a function of history of SA, TBI, and the interaction between the 2 variables. Additionally, to determine the pattern of performance over the course of the Iowa Gambling Test (IGT), scores were modeled across the 5 IGT blocks by using a varying-coefficient model. SETTING: Veterans Health Administration. PARTICIPANTS: Veterans (N=133; no SA/no TBI, n=48; no SA/yes TBI, n=51; yes SA/no TBI, n=12; yes SA/yes TBI, n=22) completed the study measures. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: IGT, Immediate and Delayed Memory Test, State-Trait Anger Expression Inventory-2, Wisconsin Card Sorting Test. RESULTS: All groups demonstrated learning over the course of the IGT, except for veterans with a history of both SA and TBI. No group differences were identified on other measures of executive functioning. CONCLUSIONS: These findings highlight the potential, unique decision-making challenges faced by veterans with a history of TBI and SA. Specialized interventions focused on overall distress reduction and means restriction may be required to prevent future self-directed violence.