Implementing an EMR-based Health-related Social Needs Screen in a Pediatric Hospital System.

INTRODUCTION: There is growing recognition of the need for effective screening methods and delivering interventions to address health-related social needs (HRSN) in hospital systems, but few studies exist on implementing such a wide-scale undertaking. This article describes the implementation and preliminary findings of a phased roll-out of an institution-wide HRSN screening. METHODS: We describe the HRSN implementation and data tracking procedures. RESULTS: During the first 13 months of the roll-out, 62,315 patient encounters from multiple clinics were eligible for screening, and 52,331 (84.0%) completed the screening. Twelve percent of patients had at least one HRSN need, and 3.5% of those had an urgent need and thus received a social work consult. CONCLUSION: Implementation of the first phase of an institution-wide HRSN screen resulted in high screening and follow-up rates among those with urgent needs, demonstrating feasibility across different clinic settings.

Characteristics Associated with Homeless Pregnant Women in Columbus, Ohio.

INTRODUCTION: The effects of homelessness on pregnant women are substantial. We aim to identify key characteristics of a group of women identified as homeless and pregnant in order to understand their history of housing, family composition, health, and demographics as a first step for future intervention. METHODS: We present cross-sectional survey data on a sample of 100 women reporting homelessness and pregnancy in the prior year in Columbus, Ohio, identified through social service and housing not for profit agencies. Our analysis uses data collected from a survey of health behaviors, housing, employment status, and demographics. Continuous measures are described with means and standard deviations, and categorical variables are described with percentages. RESULTS: The majority (81%) of the women identified as African American. Over 95% of the women were single, and 74 women reported a prior pregnancy. Almost half of the women reported being behind on rent at least one time in the last 6 months, and 43% indicated that they had lived in more than three places in the last year. Approximately 34% of the sample reported cigarette use during pregnancy, while 12% and 30% reported alcohol and illicit drug use, respectively. DISCUSSION: Women who were pregnant and experiencing homelessness in our study reported a multitude of complex and severe problems ranging from high rates of substance use, longstanding housing insecurity and financial stress. Programs hoping to successfully support women will need to address a variety of service needs while recognizing the resilience of many women.

Social Determinants of Health Needs and Pediatric Health Care Use.

OBJECTIVE: To examine the associations between family-reported social needs in primary care settings and pediatric health care use. STUDY DESIGN: Data were obtained for a sample of 56 253 children and youths (age 0-21 years) who received primary care at a large hospital-based pediatric institution between June 2018 and October 2019 to estimate a propensity score for the probability of being seen in a primary care clinic. Inverse probability weighted regression specifications were used to examine the associations between reported social needs and health care use. Families were asked about 4 social needs: housing, utilities, transportation, and food. Outcomes included the number of Emergency Department (ED), inpatient, social work, and well-child visits (only for those aged 0-2 years) in the 6 months before and after needs screening. RESULTS: Overall, 12.0% of the families reported a general social need, with 28% of those needs identified as urgent. Food and transportation needs were most common. Patients with needs were more likely to have an ED or inpatient visit at 6 months prescreening and 6 months postscreening compared with those without needs. Among children aged <2 years, those with a social need were less likely to have completed a well-child visit at 6 months postscreening compared with those without a need. CONCLUSIONS: Social needs are linked to less preventive care use and greater reliance on emergency care services. Understanding how to better assist families in need requires greater attention.

Exploring Health Literacy, Transition Readiness, and Healthcare Utilization in Medicaid Chronically Ill Youth.

PURPOSE: Youths with special healthcare needs face challenges transitioning from pediatric to adult health care. Understanding possible mechanisms contributing to poor healthcare transition could improve care. This study explores associations between health literacy (HL), transition readiness, and healthcare utilization. METHODS: Youths with special healthcare needs aged 12-18 years were recruited from a Medicaid accountable care organization (2012-2017). Outcome measures included transition readiness (Transition Readiness Assessment Questionnaire), and healthcare utilization (any well-check, hospitalization, emergency department [ED] visit, or ambulatory sensitive condition ED visit). Multivariate regression analyses examined whether HL (adequate vs. inadequate) predicted outcomes, after adjusting for covariates. Models were then created to examine whether the effect of HL on healthcare utilization was mediated by transition readiness. RESULTS: Among 417 youths with special healthcare needs, 67.1% reported adequate HL. Relative to inadequate HL, teens with adequate HL had significantly higher average Transition Readiness Assessment Questionnaire-20 scores (ß = .34, p < .001). Controlling for covariates, HL was a significant predictor of having an ambulatory sensitive condition ED visit and having any ED visits neared significance. There was a positive transition readiness mediation effect on having an ED visit, with higher transition readiness being associated with higher odds of having any ED visit in the mediation analysis. CONCLUSIONS: HL is independently associated with higher transition readiness and lower ambulatory sensitive condition ED use, but pathways of action require further study.

Improving Teen Girls' Skills for Using Electronic Health Information.

BACKGROUND: In a world increasingly dependent on the Internet for information, it is not surprising that people use the internet to find answers to their health-related questions. Research has shown that teen girls are more likely to search for health information online than boys, but that they do not feel confident in using the information they find. OBJECTIVE: To address this disparity, teen girls were engaged in the process of developing a teen-friendly, internet-based tool that explains the best way to find, evaluate, and use online health information. METHODS: Focus groups were held with girls and their parents to inform the design of the tool. After collaborating with information technology, marketing, and video production teams, a tool was developed consisting of a webpage, videos, and an interactive game. The efficacy and acceptability of the tool were tested among our target demographic through a usability trial. KEY RESULTS: Parent and teen focus groups informed the three-step design of the tool. Teen girls reported significantly higher levels of eHealth literacy after using the tool. Dissemination of the tool through a national targeted ad campaign generated web traffic to the tool. CONCLUSIONS: An internet-based training tool has been shown to improve teen girls' eHealth literacy. Findings from this developmental study can be used to inform efforts to improve eHealth literacy in adolescent girls. [HLRP: Health Literacy Research and Practice. 2021;5(1):e26-e34.] PLAIN LANGUAGE SUMMARY: This research study used teen and parent input to help design an internet-based training tool to teach teen girls the best way to use the internet to find health information. Teen girls' ability to find, understand, and evaluate online health information significantly improved after using the tool. The tool was advertised throughout the United States on various social media platforms.

Do health literacy disparities explain racial disparities in family-centered care for youths with special health care needs?

OBJECTIVE: To explore the relationship among youth health literacy, parental health literacy, and family-centered care (FCC) for youth with special health care needs (YSHCN) and assess potential racial disparities. METHODS: HL and FCC were assessed in 486 Medicaid-enrolled YSHCN (ages 12-18) and their healthcare-responsible parent/caregiver. Analyses assessed racial differences in HL and FCC for parents and youth using logistic regression. RESULTS: Half of youth and over 80 percent of parents had adequate HL (REALM score ≥62). Adequate HL was significantly lower in African Americans (AA) for both YSHCN and parents. Only 57 % of parents and 29 % of YSHCN reported FCC. AA YSHCN reported significantly lower levels of FCC compared to White YSHCN. AA parents trended lower for FCC compared to Whites, though the disparity was not significant. AA youth and parents had significantly lower odds of reporting that doctors spent enough time with them compared to Whites. CONCLUSION: Results suggest that AA and those with less than adequate health literacy experience lower FCC, however the relationship between race and health literacy does not explain the racial disparity in FCC. PRACTICAL IMPLICATIONS: Provider time spent focused on HL may not reduce the racial disparity in FCC, but opportunities for improvement exist.

Development of a measurement tool to assess local public health implementation climate and capacity for equity-oriented practice: Application to obesity prevention in a local public health system.

OBJECTIVE: The objective of this study was to develop a measurement tool to capture local public health department (LHD) organizational characteristics that align with implementation of equity-oriented practice, which may be used to gauge progress in building public health structures and functions that address the needs of vulnerable populations and reduce health inequities. METHODS: We developed and tested a measurement tool, with practitioner input, based on an implementation science framework and informed by previous work defining public health essential services and practice recommendations for health equity. Measures assessed types of vulnerable populations served by the LHD, organizational climate, and four equity-oriented practice areas, including: assessment and planning, monitoring and analysis, leadership support, and obesity prevention. We also assessed opportunities for capacity building by identifying training needs of practitioners. Primary data were collected from Missouri local health department practitioners (n = 92, 80% response rate) via an online questionnaire, with a subset of the sample providing data for test-retest reliability. RESULTS: Measures of equity-oriented implementation climate indicated areas of variability with respect to strengths and gaps across LHDs. While implementation climate was strong with respect to perceived importance (86%), a substantial proportion of LHDs cited concern over other priorities conflicting with equity-oriented implementation (32%). Likewise, a strong internal push (67%) was often accompanied by limited external political (25%) and community support (40%). Implementation climate measures generally had good to excellent reliability and were significantly associated with areas of equity-oriented practice. Frequently identified (>70%) training needs included improving skills in applying frameworks, assessment methods, and evaluating collaborations around equity. CONCLUSION: We developed a theory-based, practitioner-informed questionnaire to assess capacity for equity-oriented practice and identify opportunities for capacity building in local public health departments to engage in effective change toward health equity.

An Integrative Review of Social Determinants of Health Screenings used in Primary Care Settings.

BACKGROUND: There is limited evidence on how to implement social determinants of health (SDH) screenings. OBJECTIVE: To synthesize recent evidence investigating the implementation of SDH screening in primary care settings. DESIGN: Electronic strategies were used to find articles published between September 2008 and 2018. Articles in the review (N = 15) varied in study design and methodologic rigor, complicating the analysis. RESULTS: Many articles lacked specification on who administered the screening, where the screening was administered, and resource referral rates. The majority of the screenings were administered during the clinic visit by a medical provider. The four primary SDH domains assessed were income, housing stability, education, and employment status. CONCLUSION: More specific implementation research is needed on the best way for providers to screen for SDH in addition to how screening practices influence resource referrals, resource utilization, and health improvements.

Insights into the base-pairing preferences of 8-oxoguanosine on the ribosome.

Of the four bases, guanine is the most susceptible to oxidation, which results in the formation of 8-oxoguanine (8-oxoG). In protein-free DNA, 8-oxodG adopts the syn conformation more frequently than the anti one. In the syn conformation, 8-oxodG base pairs with dA. The equilibrium between the anti and syn conformations of the adduct are known to be altered by the enzyme recognizing 8-oxodG. We previously showed that 8-oxoG in mRNA severely disrupts tRNA selection, but the underlying mechanism for these effects was not addressed. Here, we use miscoding antibiotics and ribosome mutants to probe how 8-oxoG interacts with the tRNA anticodon in the decoding center. Addition of antibiotics and introduction of error-inducing mutations partially suppressed the effects of 8-oxoG. Under these conditions, rates and/or endpoints of peptide-bond formation for the cognate (8-oxoG•C) and near-cognate (8-oxoG•A) aminoacyl-tRNAs increased. In contrast, the antibiotics had little effect on other mismatches, suggesting that the lesion restricts the nucleotide from forming other interactions. Our findings suggest that 8-oxoG predominantly adopts the syn conformation in the A site. However, its ability to base pair with adenosine in this conformation is not sufficient to promote the necessary structural changes for tRNA selection to proceed.

Decoding on the ribosome depends on the structure of the mRNA phosphodiester backbone.

During translation, the ribosome plays an active role in ensuring that mRNA is decoded accurately and rapidly. Recently, biochemical studies have also implicated certain accessory factors in maintaining decoding accuracy. However, it is currently unclear whether the mRNA itself plays an active role in the process beyond its ability to base pair with the tRNA. Structural studies revealed that the mRNA kinks at the interface of the P and A sites. A magnesium ion appears to stabilize this structure through electrostatic interactions with the phosphodiester backbone of the mRNA. Here we examined the role of the kink structure on decoding using a well-defined in vitro translation system. Disruption of the kink structure through site-specific phosphorothioate modification resulted in an acute hyperaccurate phenotype. We measured rates of peptidyl transfer for near-cognate tRNAs that were severely diminished and in some instances were almost 100-fold slower than unmodified mRNAs. In contrast to peptidyl transfer, the modifications had little effect on GTP hydrolysis by elongation factor thermal unstable (EF-Tu), suggesting that only the proofreading phase of tRNA selection depends critically on the kink structure. Although the modifications appear to have no effect on typical cognate interactions, peptidyl transfer for a tRNA that uses atypical base pairing is compromised. These observations suggest that the kink structure is important for decoding in the absence of Watson-Crick or G-U wobble base pairing at the third position. Our findings provide evidence for a previously unappreciated role for the mRNA backbone in ensuring uniform decoding of the genetic code.

Uniformity of Peptide Release Is Maintained by Methylation of Release Factors.

Termination of protein synthesis on the ribosome is catalyzed by release factors (RFs), which share a conserved glycine-glycine-glutamine (GGQ) motif. The glutamine residue is methylated in vivo, but a mechanistic understanding of its contribution to hydrolysis is lacking. Here, we show that the modification, apart from increasing the overall rate of termination on all dipeptides, substantially increases the rate of peptide release on a subset of amino acids. In the presence of unmethylated RFs, we measure rates of hydrolysis that are exceptionally slow on proline and glycine residues and approximately two orders of magnitude faster in the presence of the methylated factors. Structures of 70S ribosomes bound to methylated RF1 and RF2 reveal that the glutamine side-chain methylation packs against 23S rRNA nucleotide 2451, stabilizing the GGQ motif and placing the side-chain amide of the glutamine toward tRNA. These data provide a framework for understanding how release factor modifications impact termination.