Photovoice in Aggression Management Training for Medical and Nursing Students-A Pilot Study.

Aggression towards medical staff in the healthcare workplace is a common global concern. Measures to mitigate consequences of patient aggression include training through Aggression Management Programs (AMPs), which have been shown to increase students' self-efficacy and self-confidence. To encourage better engagement with a 30 h required AMP training, the study piloted an adapted photovoice activity with 58 students of medicine and nursing. Each student took one to three photos depicting their perceptions, feelings, and experiences of patient aggression in the workplace and discussed them in a course session. Their photos showed types of aggression in psychiatric settings, and their consequences for patients and students. Photo strategies included showing 'actors' or toy figures in aggressive encounters; tools to control aggression in psychiatric settings (e.g., mechanical restraints and syringes); and symbolic photos showing violence to the heart (emotional impact). Adding photovoice elements to the established AMP training appeared to contribute to student reflection on their individual perspectives on patient aggression in the workplace and help students to link their subjective experiences and theoretical learning. In future, incorporating pre-test and post-test questionnaires measuring empathy, attitudes, or critical thinking could help to decipher any changes in AMP effectiveness due to the use of a self-directed photovoice activity.

Health Literacy among Pregnant Women in a Lifestyle Intervention Trial.

Health literacy plays a crucial role during pregnancy, influencing the mother's health behavior which in turn affects the unborn child's health. To date, there are only few studies that report on health literacy among pregnant women or even interventions to promote health literacy. GeMuKi (acronym for "Gemeinsam Gesund: Vorsorge plus für Mutter und Kind"-Strengthening health promotion: enhanced check-up visits for mother and child) is a cluster-randomized controlled trial, aimed at improving health literacy in pregnant women by means of a lifestyle intervention in the form of brief counseling. The women in the intervention group receive counseling on lifestyle topics, such as nutrition and physical activity, during their regular prenatal check-ups. The counseling is tailored to the needs of pregnant women. Demographic data is collected at baseline using a paper-based questionnaire. Data on health literacy is collected using the Health Literacy Survey Europe with 16 items (HLS-EU-16) at baseline and the Brief Health Literacy Screener (BHLS) questionnaire at two points during the pregnancy by means of an app, which was developed specifically for the purpose of the project. The results of the study indicate that around 61.9% of the women participating in the GeMuKi study have an adequate level of health literacy at baseline. The regression analyses (general estimating equations) showed no significant effect of the GeMuKi intervention on general health literacy as measured by the BHLS (ß = 0.086, 95% CI [-0.016-0.187]). However, the intervention was significantly positively associated with pregnancy specific knowledge on lifestyle (ß = 0.089, 95% CI [0.024-0.154]). The results of this study indicate that GeMuKi was effective in improving specific pregnancy related knowledge, but did not improve general health literacy.

Effectiveness of a Brief Lifestyle Intervention in the Prenatal Care Setting to Prevent Excessive Gestational Weight Gain and Improve Maternal and Infant Health Outcomes.

Research on perinatal programming shows that excessive gestational weight gain (GWG) increases the risk of overweight and obesity later in a child's life and contributes to maternal weight retention and elevated risks of obstetrical complications. This study examined the effectiveness of a brief lifestyle intervention in the prenatal care setting, compared to routine prenatal care, in preventing excessive GWG as well as adverse maternal and infant health outcomes. The GeMuKi study was designed as a cluster RCT using a hybrid effectiveness implementation design and was conducted in the prenatal care setting in Germany. A total of 1466 pregnant women were recruited. Pregnant women in intervention regions received up to six brief counseling sessions on lifestyle topics (e.g., physical activity, nutrition, drug use). Data on GWG and maternal and infant outcomes were entered into a digital data platform by the respective healthcare providers. The intervention resulted in a significant reduction in the proportion of women with excessive GWG (OR = 0.76, 95% CI (0.60 to 0.96), p = 0.024). Gestational weight gain in the intervention group was reduced by 1 kg (95% CI (−1.56 to −0.38), p < 0.001). No evidence of intervention effects on pregnancy, birth, or neonatal outcomes was found.

Preventive Counseling in Routine Prenatal Care-A Qualitative Study of Pregnant Women's Perspectives on a Lifestyle Intervention, Contrasted with the Experiences of Healthcare Providers.

Maternal lifestyle during pregnancy and excessive gestational weight gain can influence maternal and infant short and long-term health. As part of the GeMuKi intervention, gynecologists and midwives provide lifestyle counseling to pregnant women during routine check-up visits. This study aims to understand the needs and experiences of participating pregnant women and to what extent their perspectives correspond to the experiences of healthcare providers. Semi-structured interviews were conducted with 12 pregnant women and 13 multi-professional healthcare providers, and were analyzed using qualitative content analysis. All interviewees rated routine check-up visits as a good setting in which to focus on lifestyle topics. Women in their first pregnancies had a great need to talk about lifestyle topics. None of the participants were aware of the link between gestational weight gain and maternal and infant health. The healthcare providers interviewed attributed varying relevance regarding the issue of weight gain and, accordingly, provided inconsistent counseling. The pregnant women expressed dissatisfaction regarding the multi-professional collaboration. The results demonstrate a need for strategies to improve multi-professional collaboration. In addition, health care providers should be trained to use sensitive techniques to inform pregnant women about the link between gestational weight gain and maternal and infant health.

Strengthening Community Participation by People With Disabilities in Community-Based Group Homes Through Innovative Action Research.

In the US and beyond, a paradigm shift is underway toward community-based care, motivated by changes in policies, payment models and social norms. A significant aspect of this shift for disability activists and policy makers is ensuring participation in community life for individuals with disabilities living in residential homes. Despite a U.S. government ruling that encourages community participation and provides federal and state funding to realize it, little progress has been made. This study builds on and integrates the expanded model of value creation with relational coordination theory by investigating how the resources and relationships between care providers, adults with disabilities, family members, and community members can be leveraged to create value for residents through meaningful community participation. The purpose of our community case study was to assess and improve the quality of relationships between stakeholder groups, including direct care staff and managers, residents, family members, and the community through an action research intervention. This study took place in a residential group home in a Northeastern US community serving adults with disabilities from acquired brain injury. A pre-test post-test design was used and quantitative assessments of relational coordination were collected through electronic surveys, administered at baseline, and post-intervention. Direct care staff, supervisors, the house manager, and nursing staff completed the survey. Qualitative data were collected through focus groups, change team meetings, and key informant interviews. Direct care staff formed a change team to reflect on their baseline relational coordination data and identified the weak ties between direct care staff, family members, and the community as an area of concern. Staff chose to hold a community-wide open house to provide an opportunity to foster greater understanding among staff, residents, family, and community members. The change team and other staff members coordinated with local schools, business owners, town officials, churches, and neighbors. The event was attended by 50 people, about two-thirds from the community. Following the intervention, there was an increase in staff relational coordination with the community. While statistical significance could not be assessed, the change in staff RC with the community was considered qualitatively significant in that real connections were made with members of the community both directly and afterwards. Despite a small sample size, a residential setting where management was favorable to initiating staff-led interventions, and no comparison or control group, our small pilot study provides tentative evidence that engaging direct care staff in efforts to improve relational coordination with community members may succeed in building relationships that are essential to realizing the goal of greater participation in community life.

Critical and Creative Thinking and Photovoice: Strategies for Strengthening Participation and Inclusion.

Researchers, nonprofit organizations, and others have long used photovoice as a participatory action research method with vulnerable groups to depict, reflect on, and describe their realities, and advocate for change. Paulo Freire, whose scholarship is a foundation of photovoice, encouraged critical thinking in a popular education process to understand "the 'why' of things and facts." Creative thinking, a complementary concept that emerged in the field of education in the 1990s, involves, at its core, development, implementation, and communication of multiple original ideas. We provide a model of critical and creative thinking as an integrated process that generates knowledge as participants complete four key photovoice steps: (1) answer questions with a camera, (2) communicate in the group, (3) observe commonalities, and (4) communicate to power. We argue that each step involves teachable skills and provide practical, low-tech strategies that photovoice facilitators can use to enhance critical and creative thinking by any participant who finds it challenging to complete the four steps. Bringing a critical and creative thinking process to photovoice facilitation grounds the method in its education roots. It can enhance participation and inclusion of any vulnerable group, including people with cognitive and communication disorders due to acquired brain injury, mental illness, or substance use disorder for example. We suggest that use of the suggested strategies will result in an authentic, meaningful process that helps equalize power relationships, respects individuals as experts on their own lives, and increases the potential for data that prompt action.

How Can Cardiac Rehabilitation Promote Health Literacy? Results from a Qualitative Study in Cardiac Inpatients.

After acute care of a cardiac event, cardiac rehabilitation helps future disease management. Patients with low health literacy have been shown to have fewer knowledge gains from rehabilitation and higher all-cause mortality after acute cardiac events. Cardiac rehabilitation may be the best channel to target population with low health literacy, yet research on this topic is limited. Consequently, the main aim of the current study was to identify patient perceptions about the health literacy domains that are needed for successful rehabilitation of patients attending German cardiac rehabilitation clinics after an acute cardiac event. Five focus group interviews with 25 inpatients (80% male, 20% female) were conducted at a cardiac rehabilitation clinic in Germany. Patients were eligible to participate if they had sufficient understanding of the German language and had no other debilitating diseases. Patients identified five domains of health literacy for rehabilitation success: knowledge about their health condition; being able to find and evaluate health-related information, being able to make plans and sticking to them, assumption of responsibility over one's health and the ability to ask for and receive support. The results give an important insight into what patients perceive as important components of their cardiac rehabilitation, which can provide the basis for developing the health literacy of patients and how cardiac rehabilitation clinics respond to the recovery needs of their patients.

Understanding Determinants of Pregnant Women's Knowledge of Lifestyle-Related Risk Factors: A Cross-Sectional Study.

Research indicates that a woman's lifestyle during pregnancy influences her child's health and development. Therefore, women need to possess sufficient knowledge regarding the elements of a healthy lifestyle during pregnancy. To date, there has been little research on the assessment of lifestyle knowledge of pregnant women in the perinatal healthcare setting. This study describes the development and application of a knowledge-based questionnaire for pregnancy to be used in a lifestyle intervention trial conducted in Germany. Within the trial, pregnant women receive counselling on lifestyle topics. These topics are based on the German initiative 'Healthy Start-Young Family Network' (GiL), which provides evidence-based recommendations regarding diet and lifestyle before and during pregnancy. These serve as a basis for health professionals who provide counselling on healthy lifestyle choices during the antenatal period. The questionnaire consists of eight items, each of which can be answered using 'Yes', 'No' or 'Don't know'. The pregnant women who completed the questionnaire at baseline around the twelfth week of gestation were recruited within the host trial from gynaecological practices in Germany. Demographic variables and the respondents' answers to the questionnaire were analysed using descriptive statistics and regression analyses. Descriptive statistics show that more than 85% of participants answered the majority of questions (n = 5) correctly. Questions on whether tap water is safe and the normal range for gestational weight gain (GWG) were answered correctly by about 62% and 74% of the women, respectively, and the question on whether it is beneficial to obtain information on breastfeeding at an early stage was answered correctly by about 29%. The results of the regression analyses indicate that age, gestational week, education and income are positive predictors for answering the questionnaire correctly. Nullipara and migration background are predictors for answering the questions incorrectly. This study indicates that there are gaps in women's knowledge regarding lifestyle during pregnancy. Particular focus on certain topics, such as breastfeeding and normal GWG ranges, is still required during counselling. Our analysis shows that migration background is a predictor of insufficient knowledge and incorrect answers to the questions. Women with such backgrounds require special attention during antenatal counselling in order to cater to their needs and the gaps in their knowledge.

Value and Cost Savings From Access to Multi-disciplinary Rehabilitation Services After Severe Acquired Brain Injury.

Acquired brain injury (ABI) is a major global public health problem and source of disability. A major contributor to disability after severe ABI is limited access to multidisciplinary rehabilitation, despite evidence of sustained functional gains, improved quality of life, increased return-to-work, and reduced need for long-term care. A societal model of value in rehabilitation matches patient and family expectations of outcomes and system expectations of value for money. A policy analysis of seven studies (2009-2019) exploring outcomes and cost-savings from access to multi-disciplinary rehabilitation identified average lifetime savings of $1.50M per person, with costs recouped within 18 months. Recommendations: Increase access to multi-disciplinary rehabilitation following severe ABI; strengthen prevention focus; increase access to case management; support return-to-work; and systematically collect outcome and cost data.

Recruitment in Health Services Research-A Study on Facilitators and Barriers for the Recruitment of Community-Based Healthcare Providers.

In health services research, the recruitment of patients is oftentimes conducted by community-based healthcare providers. Therefore, the recruitment of these healthcare providers is a crucial prerequisite for successful patient recruitment. However, recruiting community-based healthcare providers poses a major challenge and little is known about its influencing factors. This qualitative study is conducted alongside a health services research intervention trial. The aim of the study is to investigate facilitators and barriers for the recruitment of community-based healthcare providers. A qualitative text analysis of documents and semi-structured interviews with recruiting staff is performed. An inductive-deductive category-based approach is used. Our findings identify intrinsic motivation and interest in the trial's aims and goals as important facilitating factors in healthcare provider recruitment. Beyond that, extrinsic motivation generated through financial incentives or collegial obligation emerged as a conflicting strategy. While extrinsic motivation might aid in the initial enrollment of healthcare providers, it rarely resulted in active trial participation in the long run. Therefore, extrinsic motivational factors should be handled with care when recruiting healthcare providers for health services research intervention trials.

[Prospects for the implementation of the Innovation Fund project GeMuKi - a cross sectional study on attitudes of health care providers regarding preventive lifestyle counselling in routine prenatal visits and infant check-ups]. / Perspektiven für die Implementierung des Innovationsfondsprojekt GeMuKi: Eine Querschnittserhebung der Einstellungen von Leistungserbringern zu einer präventiven Lebensstilberatung in den Schwangerschafts- und Kindervorsorgeuntersuchungen.

INTRODUCTION: Overweight and obesity are major public health concerns in Germany. As patients can easily be accessed via physicians' offices, this setting provides a high potential for prevention. However, the limited implementation of prevention and health promotion interventions in physicians' offices so far indicates that barriers to implementation exist. This study therefore addresses how obesity prevention interventions should be designed and implemented so that health care providers perceive them as appropriate and are willing to adopt them in their daily practice. The study is performed by taking the Innovation Fund project "GeMuKi" as an example. METHODS: A mixed-methods study was conducted. Data collection took place within the context of the GeMuKi training session that health care providers complete in preparation for implementing the intervention. Gynecologists, pediatricians, midwives, and medical assistants completed a questionnaire. The questions covered the implementation outcomes "appropriateness" and "adoption". Text entry fields were used to obtain information on feasibility as well as anticipated facilitating and hindering factors. In addition, observation protocols were prepared for each training session by the project team. The questionnaire was analyzed descriptively. Text entry fields and protocols were evaluated using qualitative content analysis. RESULTS: Four hundred and one (n=401) training participants completed the questionnaire. Almost three quarters (73 %) of the health care providers indicate that they are motivated to implement the intervention. At the same time, concerns are expressed about organizational feasibility in everyday practice. Nevertheless, 72 % expect their care to improve as a result of the project. CONCLUSION: The health care providers surveyed are positive about the implementation of the project in everyday practice. By documenting concerns about the implementation, the barriers identified can be addressed during the project course.

Health literacy among pregnant women in a lifestyle intervention trial: protocol for an explorative study on the role of health literacy in the perinatal health service setting.

INTRODUCTION: Pregnancy is a vulnerable period that affects long-term health of pregnant women and their unborn infants. Health literacy plays a crucial role in promoting healthy behaviour and thereby maintaining good health. This study explores the role of health literacy in the GeMuKi (acronym for 'Gemeinsam Gesund: Vorsorge plus für Mutter und Kind'-Strengthening health promotion: enhanced check-up visits for mother and child) Project. It will assess the ability of the GeMuKi lifestyle intervention to positively affect health literacy levels through active participation in preventive counselling. The study also explores associations between health literacy, health outcomes, health service use and effectiveness of the intervention. METHODS AND ANALYSIS: The GeMuKi trial has a hybrid effectiveness-implementation design and is carried out in routine prenatal health service settings in Germany. Women (n=1860) are recruited by their gynaecologist during routine check-up visits before 12 weeks of gestation. Trained healthcare providers carry out counselling using motivational interviewing techniques to positively affect health literacy and lifestyle-related risk factors. Healthcare providers (gynaecologists and midwives) and women jointly agree on Specific, Measurable, Achievable Reasonable, Time-Bound goals. Women will be invited to fill in questionnaires at two time points (at recruitment and 37th-40th week of gestation) using an app. Health literacy is measured using the German version of the Health Literacy Survey-16 and the Brief Health Literacy Screener. Lifestyle is measured with questions on physical activity, nutrition, alcohol and drug use. Health outcomes of both mother and child, including gestational weight gain (GWG) will be documented at each routine visit. Health service use will be assessed using social health insurance claims data. Data analyses will be conducted using IBM SPSS Statistics, version 26.0. These include descriptive statistics, tests and regression models. A mediation model will be conducted to answer the question whether health behaviour mediates the association between health literacy and GWG. ETHICS AND DISSEMINATION: The study was approved by the University Hospital of Cologne Research Ethics Committee (ID: 18-163) and the State Chamber of Physicians in Baden-Wuerttemberg (ID: B-F-2018-100). Study results will be disseminated through (poster) presentations at conferences, publications in peer-reviewed journals and press releases. TRAIL REGISTRATION: German Clinical Trials Register (DRKS00013173). Registered pre-results, 3rd of January 2019, https://www.drks.de.

Health Literacy in Pregnant Women: A Systematic Review.

Health literacy plays a crucial role during pregnancy, as the mother's health behavior influences both her own health and that of her child. To the authors' best knowledge, no comprehensive overview on evidence of the health literacy of pregnant women and its impact on health outcomes during pregnancy exists. Therefore, this review aims to assess health literacy levels in pregnant women, whether health literacy is associated with outcomes during pregnancy and whether effective interventions exist to improve the health literacy of pregnant women. A systematic literature search was conducted in PubMed and EBSCO, resulting in 14 studies. The results show mixed levels of health literacy in pregnant women. Limited health literacy is associated with unhealthy behaviors during pregnancy. Mixed health literacy levels can be attributed to the recruitment site, the number of participants and the measurement tool used. Quality assessment reveals that the quality of the included studies is moderate to good. The review revealed that randomized controlled trials and interventions to improve health literacy in pregnant women are rare or do not exist. This is crucial in the light of the mixed health literacy levels found among pregnant women. Healthcare providers play a key role in this context, as pregnant women with limited health literacy rely on them as sources of health information.

Evaluation of a computer-assisted multi-professional intervention to address lifestyle-related risk factors for overweight and obesity in expecting mothers and their infants: protocol for an effectiveness-implementation hybrid study.

BACKGROUND: The first 1000 days after conception are a critical period to encourage lifestyle changes to reduce the risk of childhood obesity and early programming of chronic diseases. A healthy lifestyle during pregnancy is also crucial to avoid high post-partum weight retention. Currently, lifestyle changes are not consistently discussed during routine health services in Germany. The objective of this study is to evaluate a novel computer-assisted lifestyle intervention embedded in prenatal visits and infant check-ups. The intervention seeks to reduce lifestyle-related risk factors for overweight and obesity among expecting mothers and their infants. METHODS: The study is designed as a hybrid effectiveness-implementation trial to simultaneously collect data on the effectiveness and implementation of the lifestyle intervention. The trial will take place in eight regions of the German state Baden-Wuerttemberg. Region were matched using propensity score matching. Expecting mothers (n = 1860) will be recruited before 12 weeks of gestation through gynecological practices and followed for 18 months. During 11 routine prenatal visits and infant check-ups gynecologists, midwives and pediatricians provide lifestyle counseling using Motivational Interviewing techniques. The primary outcome measure is the proportion of expecting mothers with gestational weight gain within the recommended range. To understand the process of implementation (focus group) interviews will be conducted with providers and participants of the lifestyle intervention. Additionally, an analysis of administrative data and documents will be carried out. An economic analysis will provide insights into cost and consequences compared to routine health services. DISCUSSION: Findings of this study will add to the evidence on lifestyle interventions to reduce risk for overweight and obesity commenced during pregnancy. Insights gained will contribute to the prevention of early programming of chronic disease. Study results regarding implementation fidelity, adoption, reach and cost-effectiveness of the lifestyle intervention will inform decisions about scale up and public funding. TRIAL REGISTRATION: German Clinical Trials Register (DRKS00013173). Registered 3rd of January 2019, https://www.drks.de.

Physical therapy and pharmacy interprofessional education in the context of a university pro bono physical therapy setting.

Interprofessional care is the standard for quality in healthcare. Interprofessional education (IPE) is an accreditation requirement in many health-care fields. This qualitative study evaluated the benefits of an interprofessional education program for Doctor of Physical Therapy (DPT) and Doctor of Pharmacy (PharmD) students in the context of a pro bono physical therapy setting focused on reducing fall risk among older adults. For each pro bono participant, PharmD and DPT students worked together to analyze fall risk of the participating older adults. PharmD students completed a medication review while the DPT students completed balance assessments. Each profession recommended adjustments to care and presented their findings to peers, faculty, and participants. Following completion of the IPE program, students completed a voluntary evaluation with seven questions requiring semi-structured written reflection regarding their IPE experience. Student reflective responses from 2014-2016 were coded by IPE faculty using a coding guide collaboratively developed by the study team. Descriptive analysis included a summary of code frequency by year, discipline and Interprofessional Education Collaborative core competency: Values and Ethics, Communication, Teams and Teamwork, and Roles and Responsibilities. Values and Ethics were the most frequently coded core competency. Students consistently noted the importance of valuing the other profession, understanding each other's roles, having good interprofessional communication, and working within a health-care team. Additional codes emerged during the analysis process. Written reflective findings suggest that hands-on collaboration, focused on a real-world problem (fall risk) relevant to both PharmD and DPT students, enabled interprofessional care that benefited students through real-world practice of skills learned during coursework, and benefited clinical participants through increased awareness of physical function and medication factors that could affect fall risk. Findings indicate that a pro bono physical therapy setting can provide hands-on learning that meets IPE accreditation requirements and student learning needs while addressing a public health concern.

Use of Photovoice to engage stakeholders in planning for patient-centered outcomes research.

BACKGROUND: Research is needed to inform patient and provider decisions about how to best care for patients who go to the emergency department with complaints of chest pain when their symptoms are due to anxiety rather than a heart problem. However, this research may not be a high priority due, in part, to a lack of awareness for the severity of anxiety symptoms and the impact of anxiety on peoples' daily lives. In this commentary article, we highlight the use of Photovoice as a unique method to share patients' lived experience of anxiety with providers, researchers, and health system leaders. MAIN TEXT: A brief background on Photovoice methods, the process of patient partner involvement in Photovoice, and the project's Photovoice results (posters, photos and captions) is presented. CONCLUSION: Photovoice achieved its intended effects of increasing awareness of all stakeholders about the burden of anxiety in patients' lives and the imperative of improving emergency department care for anxiety. This resulted in increased participation in a multi-stakeholder research partnership, critical health system support that included costs to the health system associated with implementing interventions to be tested, and submission of a patient-centered outcomes research proposal that is currently under review. In addition, Photovoice had positive benefits for participants including a therapeutic effect, may have increased group cohesion, and empowerment of patients as partners in the research process.

Healthy body, healthy mind: A mixed methods study of outcomes, barriers and supports for exercise by people who have chronic moderate-to-severe acquired brain injury.

BACKGROUND: Few people with chronic moderate-to-severe brain injury are following recommended physical activity guidelines. OBJECTIVE: Investigate effects of planned, systematic physical activity while cultivating social and emotional well-being of people with chronic moderate-to-severe brain injury. HYPOTHESIS: Moderate-to-intensive physical activity would be associated with improvements in impairment and activity limitation measures (endurance, mobility, gait speed) immediately post-intervention and six weeks later (study week 12). METHODS: The intervention was a single group pre-/post-intervention study with 14 people with chronic moderate-to-severe brain injury who live in brain injury group homes and exercised 60-90 min, 3 days per week for 6 weeks at a maximum heart rate of 50-80%. Pre-post measures (administered weeks 0, 6 and 12) were the 6 Minute Walk Test, High-level Mobility Assessment Tool and 10 Meter Walk Test. The qualitative component used a brief survey and semi-structured interview guide with participants, family members, and staff. RESULTS: Following program completion, post-intervention group changes were noted on all outcome measures and greater than minimal detectable change for people with brain injury. Three transitioned from low to high ambulatory status and maintained this change at 12 weeks. During interviews, participants agreed the program was stimulating. More than eighty percent liked working out in a group and felt better being active. CONCLUSIONS: Program impact included physical, cognitive and social/emotional aspects. Social aspects (group format, trainers) were highly motivating and supported by residents, family, and staff. Investments in transportation and recruiting and training interns to assist participants are critical to program sustainability and expansion.

Developing a Community of Practice for HIV Care: Supporting Knowledge Translation in a Regional Training Initiative.

INTRODUCTION: Ensuring knowledgeable, skilled HIV providers is challenged by rapid advances in the field, diversity of patients and providers, and the need to retain experienced providers while training new providers. These challenges highlight the need for education strategies, including training and clinical consultation to support translation of new knowledge to practice. New England AIDS Education and Training Center (NEAETC) provides a range of educational modalities including academic peer detailing and distance support to HIV providers in six states. We describe the interprofessional perspectives of HIV providers who participated in this regional program to understand success and areas for strengthening pedagogical modality, content, and impact on clinical practice. METHODS: This 2013 to 2014 mixed-methods study analyzed quantitative programmatic data to understand changes in training participants and modalities and used semistructured interviews with 30 HIV providers and coded for preidentified and emerging themes. RESULTS: Since 2010, NEAETC evolved modalities to a greater focus on active learning (case discussion, clinical consultation), decreasing didactic training by half (18-9%). This shift was designed to move from knowledge transfer to translation, and qualitative findings supported the value of active learning approaches. Providers valued interactive trainings and presentation of cases supporting knowledge translation. On-site training encouraged peer networking and sharing of lessons learned. Diversity in learning priorities across providers and sites validated NEAETC's approach of tailoring topics to local needs and encouraging regional networking. DISCUSSION: Tailored approaches resulted in improved provider-reported capacity, peer learning, and support. Future evaluations should explore the impact of this multipronged approach on supporting a community of practice and empowerment of provider teams.

Pilot study of intensive exercise on endurance, advanced mobility and gait speed in adults with chronic severe acquired brain injury.

BACKGROUND AND PURPOSE: Effects of high-intensity exercise on endurance, mobility and gait speed of adults with chronic moderate-to-severe acquired brain injury (ABI) were investigated. It was hypothesized that intensive exercise would be associated with improvements in impairment and activity limitation measures. PARTICIPANTS: Fourteen adults with chronic ABI in supported independent living who could stand with minimal or no assist and walk with or without ambulation device were studied. Eight presented with low ambulatory status. METHODS: This was a single group pre- and post-intervention study. Participants received a 6-week exercise intervention for 60-90 minutes, 3 days/week assisted by personal trainers under physical therapist supervision. Measures (6MWT, HiMAT and 10MWT) were collected at baseline, post-intervention and 6 weeks later. Repeated measures T-test and Wilcoxon Signed Ranks test were used. RESULTS: Post-intervention improvements were achieved on average on all three measures, greater than minimal detectable change (MDC) for this population. Three participants transitioned from low-to-high ambulatory status and maintained the change 6 weeks later. DISCUSSION AND CONCLUSION: People with chronic ABI can improve endurance, demonstrate the ability to do advanced gait and improve ambulatory status with 6 weeks of intensive exercise. Challenges to sustainability of exercise programmes for this population remain.

Testing novel patient financial incentives to increase breast cancer screening.

OBJECTIVES: To examine the effects of 3 types of low-cost financial incentives for patients, including a novel "person-centered" approach on breast cancer screening (mammogram) rates. STUDY DESIGN: Randomized controlled trial with 4 arms: 3 types of financial incentives ($15 gift card, entry into lottery for $250 gift card, and a person-centered incentive with choice of $15 gift card or lottery) and a control group. Sample included privately insured Tufts Health Plan members in Massachusetts who were women aged 42 to 69 years with no mammogram claim in ≥ 2.6 years. METHODS: A sample of 4700 eligible members were randomized to 4 study arms. The control group received a standard reminder letter and the incentive groups received a reminder letter plus an incentive offer for obtaining a mammogram within the next 4 months. Bivariate tests and multivariate logistic regression were used to assess the incentives' impact on mammogram receipt. Data were analyzed for 4427 members (after exclusions such as undeliverable mail). RESULTS: The percent of members receiving a mammogram during the study was 11.7% (gift card), 12.1% (lottery), 13.4% (person-centered/choice), and 11.9% (controls). Differences were not statistically significant in bivariate or multivariate full-sample analyses. In exploratory subgroup analyses of members with a mammogram during the most recent year prior to the study-defined gap, person-centered incentives were associated with a higher likelihood of mammogram receipt. CONCLUSIONS: None of the low-cost incentives tested had a statistically significant effect on mammogram rates in the full sample. Exploratory findings for members who were more recently screened suggest that they may be more responsive to person-centered incentives.