Breast Cancer Education and Empowerment in Ethiopia: Evaluating Community-Based Cancer Prevention Efforts Using the RE-AIM Framework.

Cancer prevention challenges in Ethiopia include limited community awareness and low uptake of screening, which are in part driven by a lack of culturally and linguistically relevant cancer education appropriate for the diverse indigenous communities of this never-colonized nation. In 2022, a comprehensive multi-media breast cancer (BC) awareness campaign was implemented, featuring local cancer experts and survivors, with community-based screening events in the towns of Adama and Mojo. The RE-AIM framework was used to evaluate and describe its reach, effectiveness, adoption, implementation, and maintenance. Educational pamphlets, videos, social media posts, and interviews were distributed in person and through local and national media networks, reaching tens of millions of people and resulting in 525 individuals screened, with one diagnosis of early-stage cancer. During the free screening events, an interview-administered survey of BC knowledge, attitudes, and screening practices was conducted to inform future cancer education for this population. Among 287 survey respondents, about half correctly identified swelling (46%) or changing nipples/discharge (48.4%) as signs of BC. Maintenance challenges include the lack of a national screening program. Educational resources and a mobile app, translated into the local language, encourage continued patient empowerment to perform breast self-exams. In the absence of established BC prevention programs, "pop-up" mobile screening events can be effective for mobilizing communities to get screened. The paper highlights challenges and lessons gleaned from this community-based BC awareness campaign and screening event to inform future cancer education initiatives in Ethiopia and similar resource-limited settings.

Advancing the Science of Implementation for Resource-Limited Settings through Bidirectional Learning Around Cervical Cancer Screening.

In 2020, the highest rates of cervical cancer incidence and mortality were reported in Asian and African regions of the world. Across the globe, growing evidence confirms cancer disparities among racial and ethnic minorities, low socioeconomic status groups, sexual and gender minorities, uninsured individuals, and rural residents. Recognition of these stark disparities has led to increased global efforts for improving screening rates overall and, in medically underserved populations, highlighting the urgent need for research to inform the successful implementation of cervical cancer screening. Implementation science, defined as the study of methods to promote the integration of research evidence into health care practice, is well-suited to address this challenge. With a multilevel, implementation focus, we present key research directions that can help address cancer disparities in resource-limited settings. First, we describe several global feasibility studies that acknowledge the effectiveness of self-sampling as a strategy to improve screening coverage. Second, we highlight Project ECHO as a strategy to improve providers' knowledge through an extended virtual learning community, thereby building capacity for health care settings to deliver screening. Third, we consider community health workers, who are a cornerstone of implementing public health interventions in global communities. Finally, we see tremendous learning opportunities that use contextually relevant strategies to advance the science of community engagement and adaptations that could further enhance the uptake of screening in resource-limited settings. These opportunities provide future directions for bidirectional exchange of knowledge between local and global resource-limited settings to advance implementation science and address disparities.

Medical Cannabis for the Treatment of Migraine in Adults: A Review of the Evidence.

Background: Medical cannabis (MC) has been hypothesized as an alternative therapy for migraines, given the undesirable side effects of current migraine medications. The objective of this review was to assess the effectiveness and safety of MC in the treatment of migraine in adults. Methods: We searched PubMed, EMBASE, PsycINFO, CINAHL, and Web of Science for eligible studies in adults aged 18 years and older. Two reviewers independently screened studies for eligibility. A narrative synthesis of the included studies was conducted. Results: A total of 12 publications involving 1,980 participants in Italy and the United States of America were included.Medical cannabis significantly reduced nausea and vomiting associated with migraine attacks after 6 months of use. Also, MC reduced the number of days of migraine after 30 days, and the frequency of migraine headaches per month. MC was 51% more effective in reducing migraines than non-cannabis products. Compared to amitriptyline, MC aborted migraine headaches in some (11.6%) users and reduced migraine frequency. While the use of MC for migraines was associated with the occurrence of medication overuse headaches (MOH), and the adverse events were mostly mild and occurred in 43.75% of patients who used oral cannabinoid preparations. Conclusions: There is promising evidence that MC may have a beneficial effect on the onset and duration of migraine headaches in adults. However, well-designed experimental studies that assess MC's effectiveness and safety for treating migraine in adults are needed to support this hypothesis.

'Making the most of our situation': a qualitative study reporting health providers' perspectives on the challenges of implementing the prevention of mother-to-child transmission of HIV services in Lagos, Nigeria.

OBJECTIVES: To investigate the challenges of, and opportunities for, effective delivery of prevention of mother-to-child transmission (PMTCT) services from the perspectives of primary healthcare providers in Lagos, Nigeria. DESIGN: This qualitative study consisted of nine focus groups with 59 health providers, analysed thematically. SETTING: Thirty-eight primary health facilities in central and western districts of Lagos, Nigeria. PARTICIPANTS: Participants included nurses, nursing assistants, community health workers, laboratory workers, pharmacists, pharmacy technicians, monitoring and evaluation staff and medical records personnel. RESULTS: Health providers' challenges included frustration with the healthcare system where unmet training needs, lack of basic amenities for effective and safe treatment practices, low wages and inefficient workflow were discussed. Providers discussed patient-level challenges, which included the practice of giving fake contact information for fear of HIV-related stigmatisation, and refusal to accept HIV-positive results and to enrol in care. Providers' suggestions for addressing PMTCT service delivery challenges included the provision of adequate supplies and training of healthcare workers. To mitigate stigmatisation, participants suggested home-based care, working with traditional birth attendants and religious institutions and designating a HIV health educator for each neighbourhood. CONCLUSIONS: Findings illustrate the complex nature of PMTCT service delivery and illuminate issues at the patient and health system levels. These results may be used to inform strategies for addressing identified barriers and to improve the provision of PMTCT services, thus ensuring better outcomes for women and families.

Grit as a Key Factor in the Ability of Students to Achieve Productive Global Field Research.

Global fieldwork is an invaluable educational experience for students who aspire to pursue careers as global public health professionals and cancer experts. Student-led research projects can be mutually beneficial for students and host institutions by providing opportunities for bilateral learning, sharing resources, building databases, and ultimately creating uniquely informed multi-cultural health research relevant to global communities. The USA-host country partnerships can be delicate, requiring tactful approaches to the investment in the careers of students and the field projects. The US and host institutions must therefore be selective in determining which students have the privilege of participating in global field work. This paper examines the importance of grit as a character trait contributing to the success of student-led global health research projects. Grit has been explored at length as a predictor of student success in domestic educational experiences, yet is underrepresented in the context of global education, field training, and evaluation of research and learning outcomes. This manuscript utilizes testimonials of three public health graduate students recently returned from summer cancer epidemiology education training fellowships to explore the role that grit played in completion of their independent research projects. Ultimately, this paper discusses ways to identify grit in student applicants and to foster an improved capacity for grit before, during, and after their field experiences. We share the experiences with an aim of providing participant perspectives that may be used by educators, students, and administrators at US and international partner institutions to inform global research, experiential learning, and educational and training programs.

Health workers' perspectives on barriers and facilitators to implementing a new national cervical cancer screening program in Ethiopia.

BACKGROUND: Cervical cancer disproportionately affects women in sub-Saharan Africa, compared with other world regions. In Ethiopia, a National Cancer Control Plan published in 2015, outlines an ambitious strategy to reduce the incidence and mortality of cervical cancer. This strategy includes widespread screening using visual inspection with acetic acid (VIA). As the national screening program has rolled out, there has been limited inquiry of provider experiences. This study aims to describe cancer control experts' perspectives regarding the cancer control strategy and implementation of VIA. METHODS: Semi-structured interviews with 18 participants elicited provider perspectives on cervical cancer prevention and screening. Open-ended interview questions queried barriers and facilitators to implementation of a new national screening program. Responses were analyzed using thematic analysis and mapped to the Integrated Behavioral Model. Participants were health providers and administrators with positionality as cancer control experts including screening program professionals, oncologists, and cancer focal persons at town, zone, and federal health offices at eleven government facilities in the Arsi, Bale, and Shoa zones of the Oromia region, and in the capital Addis Ababa. RESULTS: The cancer control plan and screening method, VIA, were described by participants as contextually appropriate and responsive to the unique service delivery challenges in Ethiopia. Screening implementation barriers included low community- and provider-awareness of cervical cancer and screening, lack of space and infrastructure to establish the screening center, lack of materials including cryotherapy machines for the "screen-and-treat" approach, and human resource issues such as high-turnover of staff and administration. Participant-generated solutions included additional training for providers, demand creation to increase patient flow through mass media campaigns, decentralization of screening from large regional hospitals to local health centers, improved monitoring and evaluation, and incentivization of screening services to motivate health providers. CONCLUSIONS: As the Ethiopian government refines its Cancer Control Plan and scales up screening service implementation throughout the country, the findings from this study can inform the policies and practices of cervical cancer screening. Provider perspectives of barriers and facilitators to effective cancer control and screening implementation reveal areas for continued improvement such as provider training and coordination and collaboration in the health system.

Expanding pharmacists' roles: Pharmacists' perspectives on barriers and facilitators to collaborative practice.

OBJECTIVE: The pharmacy profession is shifting from transactional dispensing of medication to a more comprehensive, patient-centered model of care. Collaborative practice agreements (CPAs) extend the role of a pharmacist to initiate, monitor, modify, and discontinue drug therapies and provide other clinical services. Although collaborative practice has been shown to improve health system efficiency and patient outcomes, little is known about how pharmacists perceive CPAs. To explore pharmacists' perspectives of CPAs, including barriers and facilitators to CPA implementation. METHODS: Semistructured key informant interviews were used to elicit information from licensed pharmacists practicing in a variety of settings in Arizona. Thematic analysis was used to identify key qualitative themes. RESULTS: Seventeen interviews of pharmacists with (n = 11, 64.7%) and without (n = 6, 35.3%) CPAs were conducted in April-May 2019. The pharmacists saw their role in CPAs as supportive, filling a care gap for overburdened providers. A heightened sense of job satisfaction was reported owing to increased pharmacist autonomy, application of advanced knowledge and clinical skills, and ability to have a positive impact on patients' health. Challenges to the implementation of CPAs included liability and billing issues, logistic concerns, some experiences with provider hesitancy, and lack of information and resources to establish and maintain a CPA. The barriers could be overcome with conscious team-building efforts to establish trust and prove the worth of pharmacists in health care teams; strategic engagement of stakeholders in the development of CPAs, including billing and legal departments; and mentorship in the CPA creation process. CONCLUSIONS: The pharmacists in this study enjoyed practicing collaboratively and had overall positive perceptions of CPAs. As health worker shortages become more dire and pharmacy practice evolves to expand the role of pharmacists in providing direct patient care, CPAs will be an important tool for restructuring care tasks within health systems.

Emergency Transportation Interventions for Reducing Adverse Pregnancy Outcomes in Low- and Middle-Income Countries: A Systematic Review.

Objective: To assess the effect of emergency transportation interventions on the outcome of labor and delivery in low- and middle-income countries (LMICs). Methods: Eleven databases were searched through December 2019: Medline/PubMed, EMBASE, Web of Science, EBSCO (PsycINFO and CINAHL), SCIELO, LILACS, JSTOR, POPLINE, Google Scholar, the Cochrane Pregnancy and Childbirth Group's Specialized Register, and the Cochrane Central Register of Controlled Trials. Methodological quality of included studies was assessed using the ROBINS-I tool. Results: Nine studies (three in Asia and six in Africa) were included: one cluster randomized controlled trial, three controlled before-and-after (CBA) studies, four uncontrolled before and after studies, and one case-control study. The means of emergency obstetric transportation evaluated by the studies included bicycle (n = 1) or motorcycle ambulances (n = 3), 4-wheel drive vehicles (n = 3), and formal motor-vehicle ambulances (n = 2). Transportation support was offered within multi-component interventions including financial incentives (n = 1), improved communication (n = 7), and community mobilization (n = 2). Two controlled before-and-after studies that implemented interventions including financial support, three-wheeled motorcycles, and use of mobile phones reported reduction of maternal mortality. One cluster-randomized study which involved community mobilization and strengthening of referral, and transportation, and one controlled before-and-after that implemented free-of-charge, 24-hour, 4 × 4 wheel ambulance and a mobile phone showed reductions in stillbirth, perinatal, and neonatal mortality. Six studies reported increases in facility delivery ranging from 12-50%, and one study showed a 19% reduction in home delivery. There was a significant increase of caesarian sections in two studies; use of motorcycle ambulances compared to car ambulance resulted in reduction in referral delay by 2 to 4.5 hours. Only three included studies had low risk of bias on all domains. Conclusion: Integrating emergency obstetric transportation with complimentary maternal health interventions may reduce adverse pregnancy outcomes and increase access to skilled obstetric services for women in LMICs. The strength of evidence is limited by the paucity of high-quality studies.

Assessing the association between medication adherence, as defined in quality measures, and disease-state control, health care utilization, and costs in a retrospective database analysis of Medicare supplemental beneficiaries using statin medications.

BACKGROUND: Adherence to medication, and related health and economic outcomes, is becoming increasingly important as populations age and as the number of Americans managing chronic conditions increases. The Pharmacy Quality Alliance (PQA) statin medication adherence measure is used in Medicare star ratings to evaluate health plan performance. Yet, limited evidence exists that investigates the association between statin medication adherence, as specified in the PQA adherence quality measure, and disease-state control, health care utilization, and costs. OBJECTIVE: To determine the association between adherence (≥80% proportion of days covered) and disease-state control, health care utilization, and health care costs for Medicare supplemental beneficiaries using statin medications eligible for inclusion in the PQA statin adherence quality measure. METHODS: This retrospective study used a cohort of eligible beneficiaries for inclusion in the PQA statin adherence measure with low-density lipoprotein (LDL) laboratory values from IBM MarketScan Medicare Supplemental Research Databases (2009-2015). A logistic regression model assessed the association between adherence and LDL control (controlled individuals had LDL levels ≤ 100 mg/dL). Health care utilization and costs during a 1-year period, from first statin medication claim, were compared between adherent and nonadherent groups using generalized linear models with log link and negative binomial distribution (utilization) or gamma distribution (costs), adjusting for covariates. Beta coefficients were used to compute cost ratios (CR) and rate ratios (RR). Cohort characteristics were assessed using t-tests, Wilcoxon rank sum tests, or chi-square tests. An a priori alpha level of 0.001 was used. RESULTS: The study cohort consisted of 77,174 beneficiaries, of whom 58,668 (76.0%) were classified as adherent to their statin medications. After controlling for other factors, odds of disease-state control were approximately 2 times higher among medication adherent beneficiaries compared with their nonadherent counterparts (OR = 2.192; 95% CI = 2.109-2.278). Multivariable analyses showed adherers experienced 4.7% fewer outpatient (RR = 0.953; 95% CI = 0.940-0.965) and 27.5% fewer inpatient (RR = 0.725; 95% CI = 0.687-0.766) visits; had 9.9% lower outpatient (CR = 0.901; 95% CI = 0.885-0.916) and 28.3% lower inpatient (CR = 0.717; 95% CI = 0.705-0.729) costs; 14.7% lower total costs (CR = 0.853; 95% CI =0.838-0.868); and 7.0% higher prescription drug costs (CR = 1.070; 95% CI = 1.052-1.089) than nonadherers. Adherence to statin medications was associated with a reduction in total costs of $157.32 per member per month. CONCLUSIONS: This retrospective database analysis demonstrated that statin adherence was associated with approximately twice the odds of having a controlled disease state compared with nonadherence in a large Medicare sample. Adherent beneficiaries had fewer outpatient and inpatient visits (lower utilization), lower outpatient and inpatient costs, and lower total costs, a calculated savings of $157.32 per member per month, despite having higher prescription drug costs. Finally, these results provide important new information by demonstrating that adherence (≥ 80%) is associated with lower health care costs in a short (1-year) time frame. DISCLOSURES: Funding for this study was provided by Pharmacy Quality Alliance; Merck & Co. (Kenilworth, NJ); and SinfoniaRx. All authors except Pickering and Black were employed by the University of Arizona College of Pharmacy or the Mel & Enid Zuckerman College of Public Health at the time of this study. Pickering is employed by the Pharmacy Quality Alliance, and Black is employed by Merck & Co. Chinthammit also reports employment with Eli Lilly and Company, and Campbell reports employment with the Pharmacy Quality Alliance. Axon reports grants from Arizona Department of Health Services, unrelated to this work. Warholak reports grants from Novartis and the Arizona Department of Health Services, unrelated to this work. This research was presented as a poster at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Annual Meeting 2019, May 18-22, 2019, in New Orleans, LA.

A retrospective cohort study evaluating the relationship between statin medication adherence and economic outcomes in commercial health plans.

BACKGROUND: Adherence to statin medications is suboptimal; however, the association of statin adherence, as defined in medication adherence quality measures, with healthcare service use and expenditure within one year has not been assessed in a commercially insured United States (US) population. OBJECTIVE: To investigate the relationship between statin adherence, as specified in the Pharmacy Quality Alliance (PQA) statin medication adherence quality measure, and healthcare resource utilization and expenditures within commercial health plans over a one-year period. METHODS: This one-year retrospective analysis involved a cohort of individuals from the Truven Health MarketScan Commercial Claims and Encounters Research Databases (2009-2015). Generalized linear models with log link and negative binomial distribution (use) or gamma distribution (expenditures) were used to assess relationships between medication adherence (≥80% proportion of days covered) and healthcare use and expenditures (adjusted to 2015 US dollars) while adjusting for covariates. Beta coefficients were used to compute cost ratios (CR) and rate ratios (RR). An alpha level of 0.001 was set a priori. RESULTS: Of 4,450,308 eligible individuals, 2,757,288 (61.9%) were classified as adherent. Multivariable analyses indicated adherent individuals had more outpatient (RR = 1.009, 95% CI = 1.007, 1.010) and fewer inpatient visits (RR = 0.756, 95% CI = 0.749, 0.762); and lower outpatient (CR = 0.965, 95% CI = 0.963, 0.967), inpatient (CR = 0.780, 95% CI = 0.779, 0.782), and total expenditures (CR = 0.975, 95% CI = 0.973, 0.977). Adherence was associated with lower per member per month total healthcare expenditures ($18.91) vs nonadherence. CONCLUSION: Within one year, statin adherence was associated with more outpatient and fewer inpatient visits, lower outpatient and inpatient expenditures, and lower total expenditures than nonadherence, within a commercially-insured population.

Regional Variation of Pancreatic Cancer Incidence in the Nile Delta Region of Egypt over a Twelve-Year Period.

BACKGROUND: Pancreatic cancer is one of the deadliest forms of cancer, with incidence rates rising in many countries around the world. Geographic variation in pancreatic cancer incidence has not been studied extensively, especially in low- and middle-income countries. The aim of this study was to characterize the distribution of pancreatic cancer incidence in the central Nile Delta region of Egypt and to examine differences by urban and rural patient residence using the nation's only population-based cancer registry. METHODS: Utilizing the Gharbiah province population-based cancer registry, data were abstracted for 1,089 pancreatic cancer cases diagnosed over twelve years from 1999 to 2010. Age- and sex-specific incidence rates were calculated and compared for urban and rural areas of the eight districts of Gharbiah. RESULTS: Age-adjusted incidence of pancreatic cancer within Gharbiah varied considerably by urban/rural patient residence and by district. Incidence rates were 1.3 times higher in urban compared to rural areas (4.45 per 100,000 in urban areas and 3.43 per 100,000 in rural areas). The highest incidence rates were observed in urban centers of Kotour, El Santa, and Kafr El-Zayat districts (12.94, 8.32, and 7.89, respectively). CONCLUSION: Incidence rates varied greatly by urban and rural areas and by district of residence in the Nile Delta region of Egypt. Future studies should examine potential environmental risk factors that may contribute to the geographic distribution of pancreatic cancer in this region.

Interventions to increase uptake of Human Papillomavirus (HPV) vaccination in minority populations: A systematic review.

Minority youth represent a unique population for public health interventions given the social, economic, and cultural barriers they often face in accessing health services. Interventions to increase uptake of Human Papillomavirus (HPV) vaccination in minority youth have the potential to reduce disparities in HPV infection and HPV-related cancers. This systematic review assesses the effectiveness of interventions to increase HPV vaccine uptake, measured as vaccine series initiation and series completion, among adolescents and young adults, aged 9-26 years old, identifying as a racial and ethnic minority or sexual and gender minority (SGM) group in high-income countries. Of the 3013 citations produced by a systematic search of three electronic databases (PubMed, Embase, and Web of Science) in November 2018, nine studies involving 9749 participants were selected for inclusion. All studies were conducted in the United States and were published from 2015 to 2018. Interventions utilized education, vaccine appointment reminders, and negotiated interviewing to increase vaccination. Participants were Black or African American (44.4%), Asian (33.3%), Hispanic or Latinx (22.2%), American Indian or Alaska Native (11.1%), and SGM (22.2%). Studies enrolled parent-child dyads (33.3%), parents alone (11.1%), and youth alone (55.6%). Vaccine series initiation ranged from 11.1% to 84% and series completion ranged from 5.6% to 74.2% post-intervention. Educational and appointment reminder interventions may improve HPV vaccine series initiation and completion in minority youth in the U.S. Given the lack of high quality, adequately powered studies, further research is warranted to identify effective strategies for improving HPV vaccine uptake for minority populations.

Interventions to increase uptake of cervical screening in sub-Saharan Africa: a scoping review using the integrated behavioral model.

BACKGROUND: Sub-Saharan Africa (SSA) experiences disproportionate burden of cervical cancer incidence and mortality due in part to low uptake of cervical screening, a strategy for prevention and down-staging of cervical cancer. This scoping review identifies studies of interventions to increase uptake of cervical screening among women in the region and uses the Integrated Behavioral Model (IBM) to describe how interventions might work. METHODS: A systematic search of literature was conducted in PubMed, Web of Science, Embase, and CINAHL databases through May 2019. Screening and data charting were performed by two independent reviewers. Intervention studies measuring changes to uptake in screening among women in SSA were included, with no restriction to intervention type, study setting or date, or participant characteristics. Intervention type and implementation strategies were described using behavioral constructs from the IBM. RESULTS: Of the 3704 citations the search produced, 19 studies were selected for inclusion. Most studies were published between 2014 and 2019 (78.9%) and were set in Nigeria (47.4%) and South Africa (26.3%). Studies most often assessed screening with Pap smears (31.6%) and measured uptake as ever screened (42.1%) or screened during the study period (36.8%). Education-based interventions were most common (57.9%) and the IBM construct of knowledge/skills to perform screening was targeted most frequently (68.4%). Willingness to screen was high, before and after intervention. Screening coverage ranged from 1.7 to 99.2% post-intervention, with six studies (31.6%) reporting a significant improvement in screening that achieved ≥60% coverage. CONCLUSIONS: Educational interventions were largely ineffective, except those that utilized peer or community health educators and mHealth implementation strategies. Two economic incentivization interventions were moderately effective, by acting on participants' instrumental attitudes, but resulted in screening coverage less than 20%. Innovative service delivery, including community-based self-sampling, acted on environmental constraints, striving to make services more available, accessible, and appropriate to women, and were the most effective. This review demonstrates that intent to perform screening may not be the major determinant of screening behavior, suggesting other theoretical frameworks may be needed to more fully understand uptake of cervical screening in sub-Saharan Africa, particularly for health systems change interventions.

Pharmacists' perceptions of the pharmacists' patient care process and performance in a simulated patient interaction.

OBJECTIVES: To (1) evaluate the use of the pharmacists' patient care process (PPCP) by licensed pharmacists through a simulated patient activity and (2) describe pharmacists' awareness and perceptions of the PPCP in the state of Arizona. DESIGN: Interviews were conducted to elicit pharmacists' perceptions and awareness of the PPCP. A simulated patient activity involved a role-play pharmacist-patient interaction in a community pharmacy setting. The PPCP was employed as the evaluative framework to assess pharmacist behavior. SETTING AND PARTICIPANTS: Pharmacists licensed in the state of Arizona practicing in various pharmacy settings were recruited through e-mail list serves and snowball recruitment. Data were collected in person, by telephone, and via video chat. OUTCOME MEASURES: Emergent qualitative themes from interviews were used to describe pharmacists' awareness and perceptions of the PPCP. The presence or absence of PPCP elements were assessed during the simulations. RESULTS: A total of 17 pharmacists were interviewed; 16 participated in the simulated activity. Of these, 7 (41.2%) participants recalled specific details regarding the PPCP process. Participants felt that the PPCP accurately reflected their daily workflow. Accordingly, a mean of 15.8 of the 19 PPCP elements was observed in simulated pharmacist-patient interactions, still allowing room for improvement in pharmacist-led care planning. Participants indicated perceived value in a shared patient care process that facilitates collaboration with myriad health professionals and as an aid to leverage pharmacists' role on health care teams. CONCLUSION: In this study, pharmacists practicing in Arizona in various settings expressed an awareness of the PPCP, felt it accurately reflected the work they do, and expressed that the tool potentially added value to their work.

Barriers and facilitators to intraorganizational collaboration in public health: Relational coordination across public health services targeting individuals and populations.

BACKGROUND: Modern public health emphasizes population-focused services, which may require collaborative work both across and within organizations. Studies have explored interorganizational collaborations, but there are little data regarding collaborations within public health organizations. PURPOSE: We measured intraorganizational collaboration and identified barriers and facilitators to collaboration within a large public health department through a mixed-methods study. METHODOLOGY/APPROACH: Our study occurred at the Maricopa County (Arizona) Department of Public Health, the third largest local public health jurisdiction in the United States. To measure collaboration, we surveyed staff using the relational coordination tool. To identify barriers and facilitators to collaboration, we performed key informant interviews with department personnel. RESULTS: Relational coordination scores varied according to the focus of the service; clinical services had significantly lower levels of relational coordination than population-focused services (p < .01). We found high levels of mutual respect and lower levels of shared knowledge across services. Facilitators to collaboration included purposive cross-program meetings around specific topics, the organization's structure and culture, and individuals' social identities. Barriers included raised expectations for collaboration, low slack resources, member's self-interest, and trust. CONCLUSION: The relational coordination of services varied significantly according to the focus of the service. Population-focused public health services had higher levels of relational coordination than individually focused services. Collaboration was facilitated and impeded by both well-known and potentially emergent factors, such as purposive cross-service meetings and organizational culture. PRACTICE IMPLICATIONS: Population-focused services possessed higher levels of collaboration than individually focused services. Intraorganizational collaboration for improved population health relies on deliberate support from senior management and structured activities to increase shared knowledge and mutual respect.

Assessing the Effect of a Telepharmacist's Recommendations During an Integrated, Interprofessional Telehealth Appointment and Their Alignment with Quality Measures.

BACKGROUND: A growing provider shortage contributes to the widening gap in significant disparities that rural communities face. To expand access to care for rural-dwelling patients with epilepsy, a national nonprofit organization initiated an integrated, interprofessional telehealth program. OBJECTIVE: To identify gaps in care based on a telepharmacist's recommendations and determine whether these recommendations aligned with Health Effectiveness Data Information Set (HEDIS) performance measures. METHODS: A retrospective chart review was conducted for patients who had an appointment with an integrated interprofessional care team composed of an epileptologist, a social worker, registered nurses, and a pharmacist. This novel approach integrated provision of care by team members at geographically distinct remote locations. The pharmacist conducted comprehensive medical reviews via video conferencing and made recommendations to the epileptologist, primary care provider, and/or patient, as appropriate. The consultation was documented in the electronic health record (EHR). The pharmacist's recommendations were categorized as 1 of the 24 preselected HEDIS performance measures or as a non-HEDIS measure. The analysis used descriptive statistics to report patient demographics and pharmacist recommendations. RESULTS: This study included 86 participants. 86 initial and 36 follow-up appointments were conducted between April 2016 and October 2017. The majority of patients were female (52%), with a mean age of 26.2 years (SD = 14.6, range 4-76) and were taking an average of 6.1 medications (SD = 3.6). 159 comorbidities or conditions were identified in the EHR along with 306 recommendations, for an average of 3.6 recommendations per patient (SD = 3.2). 41 (13.4%) recommendations aligned with preselected HEDIS measures, including medication management for depression (31.7%), hypertension (24.4%), asthma (9.8%), and comprehensive adult diabetes care (14.6%). The remaining 265 recommendations lacked sufficient documentation for categorization or failed to align with any targeted measure. CONCLUSIONS: This retrospective analysis showed that only 13% of pharmacist recommendations aligned with HEDIS quality measures. While it demonstrates the added value of clinical pharmacists in novel telehealth approaches, future work is needed to develop strategies to increase the number of recommendations aligning with HEDIS measures that adhere to national consensus treatment guidelines via telepharmacist training and improved documentation. DISCLOSURES: SinfoníaRx provided funding for this project through a grant to Warholak, Taylor, Axon, and Lott. Bingham, Boesen, Scovis, and Leal are employed by SinfoníaRx. Data from this study were presented at the American Society of Health-System Pharmacists Ambulatory Care Conference 2018; June 4, 2018; Denver, CO, and the Southwestern States Residency Conference 2018; June 15, 2018; Chandler, AZ.

AIDS-related stigmatisation in the healthcare setting: a study of primary healthcare centres that provide services for prevention of mother-to-child transmission of HIV in Lagos, Nigeria.

OBJECTIVE: To assess AIDS stigmatising attitudes and behaviours by prevention of mother-to-child transmission (PMTCT) service providers in primary healthcare centres in Lagos, Nigeria. DESIGN: Cross-sectional survey. SETTING: Thirty-eight primary healthcare centres in Lagos, Nigeria. PARTICIPANTS: One hundred and sixty-one PMTCT service providers. OUTCOME MEASURES: PMTCT service providers' discriminatory behaviours, opinions and stigmatising attitudes towards persons living with HIV/AIDS (PLWHAs), and nature of the work environment (HIV/AIDS-related policies and infection-control guidelines/supplies). RESULTS: Reported AIDS-related stigmatisation was low: few respondents (4%) reported hearing coworkers talk badly about PLWHAs or observed provision of poor-quality care to PLWHAs (15%). Health workers were not worried about secondary AIDS stigmatisation due to their occupation (86%). Opinions about PLWHAs were generally supportive; providers strongly agreed that women living with HIV should be allowed to have babies if they wished (94%). PMTCT service providers knew that consent was needed prior to HIV testing (86%) and noted that they would get in trouble at work if they discriminated against PLWHAs (83%). A minority reported discriminatory attitudes and behaviours; 39% reported wearing double gloves and 41% used other special infection-control measures when providing services to PLWHAs. Discriminatory behaviours were correlated with negative opinions about PLWHAs (r=0.21, p<0.01), fear of HIV infection (r=0.16, p<0.05) and professional resistance (r=0.32, p<0.001). Those who underwent HIV training had less fear of contagion. CONCLUSIONS: This study documented generally low levels of reported AIDS-related stigmatisation by PMTCT service providers in primary healthcare centres in Lagos. Policies that reduce stigmatisation against PLWHA in the healthcare setting should be supported by the provision of basic resources for infection control. This may reassure healthcare workers of their safety, thus reducing their fear of contagion and professional resistance to care for individuals who are perceived to be at high risk of HIV.