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

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

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

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

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

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

Adaptation of the Gabby conversational agent system to improve the sexual and reproductive health of young women in Lesotho.

Introduction: Young women from the low-middle-income country of Lesotho in southern Africa frequently report limited knowledge regarding sexual and reproductive health issues and engage in risky sexual behaviors. The purpose of this study is to describe the adaptation of an evidence-based conversational agent system for implementation in Lesotho and provide qualitative data pertaining to the success of the said adaptation. Methods: An embodied conversational agent system used to provide preconception health advice in the United States was clinically and culturally adapted for use in the rural country of Lesotho in southern Africa. Inputs from potential end users, health leaders, and district nurses guided the adaptations. Focus group discussions with young women aged 18-28 years who had used the newly adapted system renamed "Nthabi" for 3-4 weeks and key informant interviews with Ministry of Health leadership were conducted to explore their views of the acceptability of the said adaptation. Data were analyzed using NVivo software, and a thematic content analysis approach was employed in the study. Results: A total of 33 women aged 18-28 years used Nthabi for 3-4 weeks; eight (24.2%) of them were able to download and use the app on their mobile phones and 25 (75.8%) of them used the app on a tablet provided to them. Focus group participants (n = 33) reported that adaptations were culturally appropriate and provided relevant clinical information. The participants emphasized that the physical characteristics, personal and non-verbal behaviors, utilization of Sesotho words and idioms, and sensitively delivered clinical content were culturally appropriate for Lesotho. The key informants from the Ministry leadership (n = 10) agreed that the adaptation was successful, and that the system holds great potential to improve the delivery of health education in Lesotho. Both groups suggested modifications, such as using the local language and adapting Nthabi for use by boys and young men. Conclusions: Clinically tailored, culturally sensitive, and trustworthy content provided by Nthabi has the potential to improve accessibility of sexual and reproductive health information to young women in the low-middle-income country of Lesotho.

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

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

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

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

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

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

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

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

Policies and healthcare to support preconception planning and weight management: optimising long-term health for women and children.

OBJECTIVE: To explore opportunities to change increasing weight gain trajectories for women during their reproductive lives, focusing on optimising health before pregnancy. Type of program: Identifying optimal policies, health promotion and health services to support preconception health for women (with a focus on achieving a healthy weight). METHODS: Narrative description of changing policies and approaches for improving preconception health. RESULTS: Preconception preventive health priorities have been clearly determined globally and nationally. However, further rigorous research for effective interventions to facilitate healthy weight and other aspects of preconception health, alongside effective policies and strategies for implementing these interventions, remains potentially important. Barriers for women, their partners, families, communities and health professionals must be overcome and enablers fostered. The inclusion of preconception lifestyle health to tackle maternal and childhood obesity as a key priority of the World Health Organization as well as in the Australian National obesity strategy 2022-2032 are steps in the right direction. LESSONS LEARNT: Improving health across the life course requires a whole of system, integrated and equitable approach to health promotion, healthcare and policy. This includes integrating education, work, community environments, and health professionals to engage girls and young women well before pregnancy, to optimise their health. National coordination to determine core indicators and systems to evaluate and monitor change has been shown to help internationally and can be applied in Australia.

Observational study of the clinical performance of a public-private partnership national referral hospital network in Lesotho: Do improvements last over time?

Public-private partnerships (PPP) may increase healthcare quality but lack longitudinal evidence for success. The Queen 'Mamohato Memorial Hospital (QMMH) in Lesotho is one of Africa's first healthcare PPPs. We compare data from 2012 and 2018 on capacity, utilization, quality, and outcomes to understand if early documented successes have been sustained using the same measures over time. In this observational study using administrative and clinical data, we assessed beds, admissions, average length of stay (ALOS), outpatient visits, and patient outcomes. We measured triage time and crash cart stock through direct observation in 2013 and 2020. Operational hospital beds increased from 390 to 410. Admissions decreased (-5.3%) while outpatient visits increased (3.8%). ALOS increased from 5.1 to 6.5 days. Occupancy increased from 82% to 99%; half of the wards had occupancy rates ≥90%, and Neonatal ward occupancy was 209%. The proportion of crash cart stock present (82.9% to 73.8%) and timely triage (84.0% to 27.6%) decreased. While overall mortality decreased (8.0% to 6.5%) and neonatal mortality overall decreased (18.0% to 16.3%), mortality among very low birth weight neonates increased (30.2% to 36.8%). Declines in overall hospital mortality are promising. Yet, continued high occupancy could compromise infection control and impede response to infections, such as COVID-19. High occupancy in the Neonatal ward suggests that the population need for neonatal care outpaces QMMH capacity; improvements should be addressed at the hospital and systemic levels. The increase in ALOS is acceptable for a hospital meant to take the most critical cases. The decline in crash cart stock completeness and timely triage may affect access to emergency treatment. While the partnership itself ended earlier than anticipated, our evaluation suggests that generally the hospital under the PPP was operational, providing high-level, critically needed services, and continued to improve patient outcomes. Quality at QMMH remained substantially higher than at the former Queen Elizabeth II hospital.

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

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

Information exchange among providers and patient-centeredness in transitional care: A five-year retrospective analysis.

BACKGROUND: Responding to the shift toward value-based care, hospitals engaged in widespread experimentation of implementing transitional care (TC) strategies to improve patient experience and reduce unnecessary readmissions. However, which groups of these strategies are most strongly associated with better outcomes remains unknown. METHODS: Using a retrospective longitudinal design, we collected hospitals' TC strategy implementation data for 370 U S. hospitals and obtained claims data for 2.4 million Medicare fee-for-service beneficiaries hospitalized at them from 2009 to 2014. We applied estimated mixed-effects regression models controlling for patient, hospital, and community covariates to assess relationships between TC strategy groups and trends in hospitals' 30-day hospital readmissions, with observation stay and mortality rates as secondary outcomes. RESULTS: Hospitals' adoption of TC groups was associated with higher readmission rates at baseline and larger readmission rate reductions compared to not adopting any of 5 TC groups. The TC group including timely information exchange across care settings, engaging patients and caregivers in education, and/or identifying and addressing patients' transition needs was associated with the largest reductions. Hospitals not implementing any of the 5 TC groups had higher mortality rates and lower observation stay rates throughout the study period. CONCLUSIONS: Our findings suggest that timely information sharing among providers across the care continuum and engaging patients in discharge planning and education may correspond with reduced readmissions. IMPLICATIONS: Our research suggests that hospitals responded to shifts in policy by implementing a diversity of TC strategy combinations; it also provides guidance regarding which combinations of TC strategies corresponded with larger readmission reductions.

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

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

Implementation of Online Research Training and Mentorship for Sub-Saharan African Family Physicians.

Background: To improve the delivery and reach of primary health care, a robust scientific foundation driven by research is needed. However, few family physicians conduct research, especially in sub-Saharan Africa. Early-career and trainee family physicians are a key part of the primary care research pipeline and have an expressed need for research training and mentorship. Objective: AfriWon Research Collaborative (ARC) was an online research training and mentorship pilot program whose objective was to increase research activity among participants from AfriWon Renaissance, the family physician young doctors' movement of sub-Saharan Africa. Methods: ARC utilized a 10-module online curriculum, supported by peer and faculty e-mentorship, to guide participants through writing a research protocol. The feasibility, acceptability, and scalability of this program was evaluated via a mixed-methods RE-AIM-guided process evaluation using descriptive statistics and inductive/deductive thematic analysis. Findings: The pilot reached participants from Botswana, Democratic Republic of the Congo, Ghana, Nigeria and Sierra Leone and was adopted by mentors from 11 countries across three continents. Four of the 10 pilot participants completed a full research protocol by the end of the six-month core program. Seven out of the 10 participants, and nine out of the 15 mentors, planned to continue their mentorship relationships beyond the core program. The program helped instill a positive research culture in active participants. Some participants' and mentors' engagement with the ARC program was limited by confusion over mentorship structure and role, poor network connectivity, and personal life challenges. Conclusions: Online research training and mentorship for trainee and early-career family physicians in sub-Saharan Africa is feasible and acceptable to participants and mentors. Similar programs must pay careful attention to mentorship training and provide a flexible yet clearly organized structure for mentee-mentor engagement. Additional work is needed to determine optimal implementation strategies and ability to scale.

Improving the health of young African American women in the preconception period using health information technology: a randomised controlled trial.

BACKGROUND: Preconception care focuses on improving women's health before pregnancy as a means to improve their health and future pregnancy outcomes. How to effectively deliver such care is unknown. The aim of this research was to assess the impact of an embodied conversational agent system on preconception risks among African American and Black women. METHODS: We did an open-label, randomised controlled trial of women aged 18-34 years, self-identified as African American or Black, or both, and not pregnant, recruited from 35 states in the USA. Sealed allocation envelopes (in permuted blocks of six and eight, prepared using a random number generator) were opened after enrolment. Intervention participants received an online conversational agent called Gabby that assessed 102 preconception risks and delivered 12 months of tailored dialogue using synthesised speech, non-verbal behaviour, visual aids, and health behaviour change techniques such as motivational interviewing. The control group received a letter listing their preconception risks and encouraging them to talk with a clinician. The primary outcome was the proportion of identified risks at the action or maintenance stage of change at months 6 and 12. The study is registered with ClinicalTrials.gov, NCT01827215. FINDINGS: From March 11, 2014, through July 8, 2018, 528 women recruited from 35 states and 242 cities across the USA received the Gabby intervention (n=262) or were assigned to the control group (n=266). Participants identified a mean of 21 preconception risks per woman (SD 9·9). In the intention-to-treat analysis, at 6 months, intervention women reported reaching the action or maintenance stage of change for 50·0% (SD 28·9) of those preconception risks identified compared with 42·7% (28·3) in the control group (incidence rate ratio 1·16, 95% CI 1·07-1·26; p=0·0004). This result persisted at 12 months. INTERPRETATION: The Gabby system has the potential to improve women's preconception health. Further research is needed to determine if improving preconception risks impacts outcomes such as preterm delivery. FUNDING: National Institute for Minority Health and Health Disparities.

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

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

Using Health Information Technology to Engage African American Women on Nutrition and Supplement Use During the Preconception Period.

Importance: Healthy nutrition and appropriate supplementation during preconception have important implications for the health of the mother and newborn. The best way to deliver preconception care to address health risks related to nutrition is unknown. Methods: We conducted a secondary analysis of data from a randomized controlled trial designed to study the impact of conversational agent technology in 13 domains of preconception care among 528 non-pregnant African American and Black women. This analysis is restricted to those 480 women who reported at least one of the ten risks related to nutrition and dietary supplement use. Interventions: An online conversational agent, called "Gabby", assesses health risks and delivers 12 months of tailored dialogue for over 100 preconception health risks, including ten nutrition and supplement risks, using behavioral change techniques like shared decision making and motivational interviewing. The control group received a letter listing their preconception risks and encouraging them to talk to a health care provider. Results: After 6 months, women using Gabby (a) reported progressing forward on the stage of change scale for, on average, 52.9% (SD, 35.1%) of nutrition and supplement risks compared to 42.9% (SD, 35.4) in the control group (IRR 1.22, 95% CI 1.03-1.45, P = 0.019); and (b) reported achieving the action and maintenance stage of change for, on average, 52.8% (SD 37.1) of the nutrition and supplement risks compared to 42.8% (SD, 37.9) in the control group (IRR 1.26, 96% CI 1.08-1.48, P = 0.004). For subjects beginning the study at the contemplation stage of change, intervention subjects reported progressing forward on the stage of change scale for 75.0% (SD, 36.3%) of their health risks compared to 52.1% (SD, 47.1%) in the control group (P = 0.006). Conclusion: The scalability of Gabby has the potential to improve women's nutritional health as an adjunct to clinical care or at the population health level. Further studies are needed to determine if improving nutrition and supplement risks can impact clinical outcomes including optimization of weight. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT01827215.

Care Transitions From Patient and Caregiver Perspectives.

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

Project RED Impacts Patient Experience.

BACKGROUND: Hospitalized patients are frequently unprepared to care for themselves after discharge often leading to unplanned hospital readmission. One strategy to reduce readmission rates is improving the quality of patient education and preparation before hospital discharge. The ReEngineered Discharge (RED) is a standardized hospital-based program designed to provide patients and caregivers the information they need to continue care at home. OBJECTIVES: We sought to study the impact of the RED intervention on posthospitalization adult patient experience scores in an urban academic safety-net hospital. METHODS: We conducted a descriptive study of a pilot program that compared posthospitalization survey responses to the Press Ganey survey item "Instructions were given about how to care for yourself at home." We compared the survey results for 3 groups of adult patients: those receiving the RED program, those receiving a standard discharge on the same hospital unit, and those receiving a standard discharge on other hospital units. RESULTS: A greater percentage of adult patients who received the RED discharge program rated the quality of their discharge as "very good" as compared to those receiving a standard discharge on the same hospital unit and those receiving a standard discharge on other hospital units (61%, 35%, and 41%, respectively, P = .0001). CONCLUSION: Delivery of a standardized hospital discharge program resulted in a larger proportion of top-box "very good" responses on a Press Ganey posthospitalization survey. Future research should examine whether hospital-based transition programs can sustain improvement in patient experience measures and whether these improvements can be observed in other patient populations.