Determinants of Human Papillomavirus (HPV) vaccination intentions among young adult college students using the theory of planned behavior.

Purpose: To determine college students' intentions to be Human Papillomavirus (HPV) vaccinated. Methods: The study was comprised of college students aged 18-45 years. A survey was developed based on the Theory of Planned Behavior (TPB). The significance of the TPB constructs-attitude, subjective norms, and perceived behavioral control-and an additional construct-knowledge-in predicting intention were assessed. Results: The regression model containing attitude, subjective norms and perceived behavioral control accounted for 40% of the variance in intention. Attitude and subjective norms were significant predictors, while perceived behavioral control was not. Provider recommendation was the only significant covariate. Knowledge did not significantly contribute to the model. Discussion: The TPB was useful in predicting HPV vaccination intentions. A focus on attitude, subjective norms and provider recommendation may be useful in creating new or enhancing existing interventions.

A narrative review of the well-being and burnout of U.S. community pharmacists.

OBJECTIVES: The purpose of this narrative review is to summarize the literature on well-being and burnout among community pharmacists in the U.S. and provide recommendations for future research. METHODS: Relevant literature was identified by searching PubMed for combinations of keywords such as "burnout" and "well-being" combined with "pharmacists." Titles and abstracts were reviewed for relevancy, and full text articles were reviewed when applicable. RESULTS: While burnout is defined by its 3 core symptoms of emotional exhaustion, depersonalization, and low personal accomplishment, well-being is more challenging to define and measure, which has led to it being less studied. Community pharmacists faced high rates of burnout, low quality of life (QOL), and extreme fatigue prior to the COVID-19 pandemic, a situation that has likely only worsened. Factors such as workload, the type of community pharmacy, the level of education or training of the pharmacist, and stress may be some of the contributors to high rates of burnout. Clinician burnout may be related to high rates of mental health disorders seen in pharmacists, may impact patient safety and satisfaction, and may affect productivity and costs to employers and the healthcare system overall. There has been no research into interventions or strategies to support well-being and reduce burnout among community pharmacists, but having a workplace that is perceived as supporting well-being may have some impact. Recommendations for future research include the following: (1) define well-being, (2) explore why various factors support well-being or contribute to burnout, (3) determine the impact of community pharmacists experiencing well-being or burnout, and (4) develop strategies to support well-being and reduce burnout that are specific to community pharmacy. CONCLUSION: There is a sparsity of evidence regarding community pharmacist well-being and burnout. Further research is needed to generate the evidence needed to support interventions that are specific to the unique work setting of community pharmacists.

An examination of the emerging field of community paramedicine: a national cross-sectional survey of community paramedics.

BACKGROUND: Community Paramedicine is an evolving community-based model that expands paramedic roles from emergency and transport care to a focus on non-emergent and preventive health services tailored to local community needs. Though community paramedicine is a growing field and acceptance is gradually increasing, there is limited information on community paramedics (CPs) perceptions of their expanded roles. The study's aim is to assess CPs' perceptions about their training, roles, role clarity, role readiness, role satisfaction, professional identity, interprofessional collaboration, and the future of the community paramedicine care model. METHODS: Using the National Association of Emergency Medical Technicians-mobile integrated health (NAEMT-MIH) listserv, a cross-sectional survey was conducted in July/August 2020 using a 43-item web-based questionnaire. Thirty-nine questions evaluated CPs' training, roles, role clarity, role readiness, role satisfaction, professional identity, interprofessional collaboration, and program/work characteristics. Four open-ended questions examined perceptions of the future of community paramedicine care models and challenges/opportunities encountered during the COVID-19 pandemic. Data was analyzed using Spearman's correlation, Wilcoxon Mann-Whitney U, and Kruskal-Wallis tests. Open-ended questions were analyzed using qualitative content analyses. RESULTS: Responses from fifty-seven CPs were analyzed. Most (80%) completed didactic and/or clinical training. Nearly all respondents (96.5%) performed health assessments; only 38.6% administered vaccines. Overall, participants were neutral about their role readiness with a mean score of 3.3/5.0. The mean role clarity was 15.5 (range 4-29; higher scores = higher clarity), professional identity was 46.8 (range 30-55; higher scores = higher identity), role satisfaction was 4.4/5 with 5 = very satisfied, and interprofessional collaboration was 9.5/10 (10 = very important). Role clarity training (rho = 0.4, p = 0.0013) and higher interprofessional collaboration (rho = 0.4, p = 0.0015) were found to be significantly associated with the enhancement of professional identity. Respondents who completed training showed higher role satisfaction compared to those who did not (p = 0.0114). COVID-19 challenges included keeping up with emerging policies/procedures, CPs' well-being, and inadequate funding to meet service needs; opportunities identified included service delivery expansion and CPs meeting community needs in a flexible manner. Respondents reported that sustainable payment models, expanding services, and geographic reach were important to the future of community paramedicine. CONCLUSIONS: Interprofessional collaboration is important to fulfill CPs roles. Role clarity and readiness could be improved, which aligns with the emerging nature of community paramedicine. The future of the community paramedicine care model is dependent on funding and expanding reach of services.

Evaluating the relationship between patient activation and health-related quality of life (HRQOL) in patients with pancreatic cancer (PwPC).

PURPOSE: Advanced pancreatic cancer is synonymous with a high mortality rate, debilitating symptom profile, and minimal prolongation in overall survival. Therefore, health-related quality of life (HRQOL) is important in patients with pancreatic cancer (PwPC). In chronic conditions, patient activation is positively associated and higher HRQOL. However, no known study has evaluated patient activation, HRQOL, and their association in PwPC. METHODS: A 43-item cross-sectional survey assessed patient activation and HRQOL of patients with locally advanced and metastatic pancreatic cancer undergoing chemotherapy. Variables were analyzed descriptively, and relationships were assessed using bivariate statistics (sig p < 0.05). RESULTS: Fifty-six patients participating in the study had an average age of 69.5 ± 11.1 years, and the majority were females (51.8%), Caucasians (61.8%), married/partnered (64.3%), and had at least a college degree (59%). Almost half were at stage 4 (48.2%), and most were newly diagnosed (66.1%). Mean patient activation score was 63.5 ± 17.2 (scale range: 0-100), with most at higher activation levels of 3 or 4 (66.7%). Mean HRQOL score of 41.0 ± 12.7 (scale range: 0-72) was low. Patient activation levels, age, education level, and gender explained 21% of variation in overall HRQOL scores. Patients at activation level 4 had significantly higher overall HRQOL versus those at lower activation (level 1 or 2). Higher patient activation was significantly associated with having either private insurance only or multiple insurances and being partnered. CONCLUSION: Patient activation significantly predicted HRQOL in PwPC despite the low sample size. Initiatives to increase patient activation should focus on patients of low socioeconomic status and those without partner support.

Comparing survival outcomes between neoadjuvant and adjuvant chemotherapy within breast cancer subtypes and stages among older women: a SEER-Medicare analysis.

BACKGROUND: This study aimed to compare survival outcomes of neoadjuvant (NAC) and adjuvant chemotherapy (AdC) within each breast cancer subtype and stage among older women. METHODS: Older (≥ 66 years) women newly diagnosed with stage I-III invasive ductal breast cancer during 2010-2017 and treated with both chemotherapy and surgery within one year were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Analyses were performed within each of six groups, jointly defined based on subtype (hormone receptor [HR]-positive/human epidermal growth factor receptor 2 [HER2]-negative, HER2 + , and triple-negative) and stage (I-II and III). Kaplan-Meier curves and multivariable Cox models were used to compare overall and recurrence-free survival between NAC and AdC, with optimal full matching performed for confounding adjustment. RESULTS: Among 8,495 included patients, 8,329 (20.6% received NAC) remained after matching. Before multiple testing adjustment, Cox models showed that NAC was associated with a lower hazard for death among stage III HER2 + patients (hazard ratio = 0.347, 95% confidence interval CI 0.161-0.745) but a higher hazard for death among triple-negative patients (stage I-II: hazard ratio = 1.558, 95% CI 1.024-2.370; stage III: hazard ratio = 2.453; 95% CI 1.254-4.797). A higher hazard for death/recurrence was associated with NAC among stage I-II HR + /HER2- patients (hazard ratio = 1.305, 95% CI 1.007-1.693). No significant difference remained after multiple testing adjustment. CONCLUSIONS: The opposite trends (before multiple testing adjustment) of survival comparisons for advanced HER2 + and triple-negative disease warrant further research. Caution is needed due to study limitations such as cancer stage validity.

Perceived discrimination in the community pharmacy: A cross-sectional, national survey of adults.

BACKGROUND: Discrimination experiences have been documented in various health care settings; little is known about discrimination experiences in the community pharmacy setting. OBJECTIVES: This study aimed to (1) describe perceived everyday discrimination, including racial discrimination, in community pharmacies, (2) examine factors associated with perceived everyday discrimination, (3) examine the relationship between perceived racial discrimination and delays in picking up prescriptions, and (4) examine the relationship between perceived racial discrimination and forgoing prescriptions. METHODS: A cross-sectional survey was conducted in 2021 with a U.S. Qualtrics research panel. The 9-item Everyday Discrimination Scale (EDS) was used to assess perceived discrimination (range 9-45, higher scores indicate higher perceived discrimination). One question asked whether respondents perceived racial discrimination. Two questions asked whether respondents delayed or forwent getting a prescription(s) in the past year. Descriptive statistics were calculated for all variables. A generalized linear model examined factors associated with perceived discrimination; logistic regression examined the relationships between perceived racial discrimination and delays in getting or forgoing prescription(s). RESULTS: Participants (n = 578) were 40.2 (±16.5) years old. Most were white (55.5%), 24.4% were black, and 29.4% were Hispanic or Latino. The mean EDS score was 16.5 (±8.8); 18.7% perceived racial discrimination. Overall, 36.3% and 33.0% reported a delay in getting and forgoing their prescriptions, respectively. Age (P < 0.0001), sexual identity or orientation (P = 0.010), ethnicity (P = 0.049), annual income (P = 0.012), and prescription insurance (P = 0.008) were associated with perceived discrimination. Those with perceived racial discrimination had significantly higher odds of a delay in getting their prescription(s) than those without perceived racial discrimination (odds ratio 2.6 [95% CI 1.3-5.3]). CONCLUSIONS: Study findings elucidate discrimination experiences in the community pharmacy and the impact of racial discrimination on individuals' decision in obtaining their medications in a timely manner. Community pharmacy staff need to recognize their implicit biases and obtain training on best practices that promote equitable treatment of diverse patients.

Using the Theory of Planned Behavior to assess community pharmacists' intention to prescribe using the Formulary and Protocol Compendia.

BACKGROUND: Oregon pharmacists can autonomously prescribe hormonal contraception, naloxone, and various medications and devices from a Formulary and Protocol Compendia (FPC). Prescribing using the FPC has seen limited uptake. OBJECTIVES: (1) Assess Oregon community pharmacists' intention to prescribe using the FPC; (2) Determine the impact that attitudes, subjective norms (SN), perceived behavioral control (PBC), perceived obligation, and past prescribing behavior have on pharmacists' intention to prescribe; (3) Examine the relationship between beliefs and pharmacists' attitudes, subjective norms, and perceived behavioral control. METHODS: This study was conducted as a cross sectional survey, which was developed based on the results of a previously conducted research project. A modified version of the Theory of Planned Behavior (TPB) was the study framework. All Oregon community pharmacists with a public email address were invited to participate. The questionnaire collected information on TPB constructs as well as demographic and practice information. TPB constructs were measured directly (intention, attitudes, SN, PBC, perceived obligation, and past prescribing behavior) and indirectly (attitudes, SN, and PBC). Descriptive statistics were used for all items. Multiple linear regression was used to assess Objectives 2 and 3. RESULTS: There were 175 useable responses included in the analysis of the estimated 1015 community pharmacists that received the survey invitation (17%). Respondents had 16.5 ± 13.3 years in practice, 60% held a PharmD degree, and 69% had prescribed in some manner before. Mean intention to prescribe using the FPC was 5.0 ± 1.5 (7-point scale with 7 indicating higher intention). Attitudes, SN, PBC, and PO were significant predictors of intention to prescribe, while past prescribing behavior was not (Adj R2 = 0.741, p < .0001). Attitudes were explained by beliefs about increasing patient access (p = .0179). PBC was explained by beliefs about having policies and procedures in place (p = .004) and feeling comfortable prescribing (p = .008). CONCLUSIONS: Oregon community pharmacists have a positive intention to prescribe using the FPC, but actual uptake remains low. Efforts to increase uptake should focus on the beliefs that contribute most strongly to pharmacist intention.

Opioid harm reduction: A scoping review of physician and system-level gaps in knowledge, education, and practice.

Background: Harm reduction includes treatment and prevention approaches rather than abstinence, as a public health strategy for mitigating the opioid epidemic. Harm reduction is a new strategy for many healthcare professionals, and gaps in knowledge and practices may lead to barriers to optimal treatment. Our objective was to identify and describe gaps in physicians' knowledge, education, and practice in harm reduction strategies related to opioid overdose. Methods: We searched the PubMed, CINAHL, and Web of Science databases for articles published between 2015 and 2021, published in English, containing empirical evidence, addressing opioid harm reduction, and identifying gaps in physicians' knowledge, education, or practice. Results: Thirty-seven studies were included. Studies examined how physicians' perceptions or stigma influenced harm reduction efforts and addressed clinical knowledge gaps in overdose treatment and prevention and OUD treatment. Less than half of the studies addressed access issues at the system level, above the individual healthcare professional. Conclusion: Individual-level interventions should be addressed with professional continuing education and curricular-based changes through experiential and interprofessional education. System-level gaps can be remedied by increasing patient access to care, creating policies favorable to harm reduction, and extending resources to provide harm reduction strategies.

Neoadjuvant chemotherapy use trends among older women with breast cancer: 2010-2017.

PURPOSE: This study assessed chemotherapy use trends before (neoadjuvant chemotherapy [NAC]) or after surgery (adjuvant chemotherapy [AdC]) among older women with breast cancer and examined factors related to NAC receipt. METHODS: Women (> 65 years) diagnosed with stage I-III breast cancer during 2010-2017 who received NAC or AdC were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. All patients were stratified into six strata based on subtype (hormone receptor-positive/human epidermal growth factor receptor 2-negative [HR + /HER2-], HER2 + , and triple-negative breast cancer [TNBC]) and stage (I-II and III). Cochran-Armitage tests were performed to test temporal trends of NAC use in each stratum. Multivariable logistic regression analyses were performed to identify factors (sociodemographic and clinical) related to NAC use. RESULTS: Among included older (mean ± standard deviation: 72.3 ± 5.2 years) women (N = 8,495) with stage I-III breast cancer, NAC use increased from 11.7% (2010) to 32.6% (2017). Significant increases in NAC were found in all strata (p < .0001) with more substantial increases in HER2 + disease and TNBC compared to HR + /HER2- disease. Multivariable logistic regressions identified the youngest age category (66-69 years) and later stage as significant (p < 0.05) predictors of NAC receipt in most strata, in addition to diagnosis year. CONCLUSION: Similar to the overall breast cancer population, NAC use increased among a population of older women. NAC was received by most patients with stage III HER2 + disease or TNBC in more recent years and was more common among younger elderly women and those in stage III.

General versus disease-specific health literacy in patients with breast cancer: a cross-sectional study.

Health literacy is recognized as a critical factor affecting communication across the continuum of cancer care and plays a key role in patients' ability to meaningfully discuss their condition with healthcare providers. However, there is no consensus on the best approach to measure health literacy in clinical practice. The aims of this study were to compare general and disease-specific measurements of health literacy in patients with breast cancer as well as examine their relationships with patient-provider communication. During office visits, patients with HER-2 + breast cancer who received care at oncology clinics with value-based models of care completed a survey including the 6-item cancer health literacy tool (CHLT-6), 6-item newest vital sign (NVS), 2 items measuring difficulty of patient-provider communication, and 11 demographic/clinical items. The mean age of 146 participants was 57.1 ± 10.8 years. Most participants had adequate general health literacy as measured by the NVS (79%) and a high probability of adequate cancer health literacy (≥ 0.7) as measured by the CHLT-6 (92%). Most patients easily communicated with healthcare providers (90.2%) and understood information they provided (83.5%). However, there was no significant relationship between patient-provider communication and health literacy. Both the CHLT-6 and NVS may be useful tools to assess the health literacy of patients with cancer in clinical practice. Study findings of adequate health literacy and ease of communication might have been influenced by the value-based care models adopted by participating clinics. Further research in more diverse samples of patients with cancer and different types of oncology practice settings is warranted.

Pharmacists' intention to prescribe under new legislation.

BACKGROUND: In 2017, Oregon passed legislation that authorized pharmacists to autonomously prescribe specified medications or devices that were included on the Formulary and Protocol Compendia (FPC). Factors that impact pharmacists' intention to prescribe from the FPC are not currently known. OBJECTIVES: Identify factors that influence pharmacists' intention to prescribe. METHODS: The Theory of Planned Behavior (TPB) served as the framework. Three focus groups were conducted with Oregon pharmacists between May and June 2019 to elicit salient beliefs about prescribing related to TPB constructs, including attitudes, subjective norms, perceived behavioral control, and perceived obligation. Two investigators conducted a qualitative content analysis and reached agreement on names of categories during consensus meetings. A codebook was created after analysis of the first focus group and used to guide the remaining analysis. Participants reported background information and awareness of prescribing rules via a questionnaire; descriptive statistics were used to report background information and the prescribing awareness summary score. RESULTS: Thirteen participants had 14.1 ± 10.8 years of pharmacist experience. Most earned a Doctor of Pharmacy degree (84.6%) and worked in a community pharmacy setting (61.5%). The mean score on the awareness assessment was 6.3 ± 0.9 (7 = highest awareness). The majority (76.9%) had previous prescribing experience. Attitudes were found to be shaped by behavioral beliefs related to the impact of pharmacist prescribing on patient-centered care and on practice transformation. Normative beliefs were primarily driven by outside groups past experiences with pharmacists and pharmacies. Control beliefs included the following categories: operational readiness; the relationships between comfort, competence, and confidence; and Board of Pharmacy requirements. CONCLUSIONS: TPB was useful for exploring pharmacists' beliefs related to their intention to prescribe using the FPC. Determining the relative importance of these factors in a broader population will enable stakeholders to develop interventions to improve uptake of prescribing via the FPC.

Perceptions and predictors of intention to receive the COVID-19 vaccine.

BACKGROUND: The control of the Coronavirus Disease 2019 (COVID-19) pandemic may be dependent on widespread receipt of an effective vaccine. It is important to understand patient health-related behaviors and perceptions to guide public health vaccination strategies. OBJECTIVES: To examine perceptions of COVID-19 and vaccination beliefs, and identify predictors of intention to receive the COVID-19 vaccine in the US. METHODS: A cross-sectional, web-based survey guided by the Health Belief Model was conducted using a web-based Qualtrics survey panel of US adults. The main outcome was the intention to receive the COVID-19 vaccine if offered. Additional measures included: demographics, perceptions of COVID-19 severity, risk and susceptibility, views of a potential COVID-19 vaccine, virus and vaccine information sources, vaccine beliefs and behaviors, and seasonal flu vaccine history. RESULTS: A total of 1047 complete responses were included. Females had lower odds of intending to receive the COVID-19 vaccine than males (AOR = 0.54, 95% CI: 0.36-0.80). Those with a two-year degree/some college had lower odds of intending to receive the COVID-19 vaccine compared to those with a high school degree/GED (AOR = 0.59, 95% CI: 0.36-0.97). Respondents who perceived the severity of the virus to be higher, perceived a greater COVID-19 vaccine benefit, and perceived greater general vaccine benefits had higher odds of intending to receive a COVID-19 vaccine (AOR = 1.44, 95% CI: 1.09-1.91; AOR = 2.82, 95% CI: 2.24-3.56; AOR = 1.77, 95% CI 1.41-2.21, respectively). CONCLUSIONS: In this study, intention to receive the COVID-19 vaccine varied across demographics, perceived virus severity, COVID-19 vaccine and general vaccine beliefs. Successful implementation of a COVID-19 immunization strategy by healthcare providers and public health officials will need to incorporate diverse COVID-19 vaccination education strategies tailored to patients' health beliefs.

Return-On-Investment for Billable Pharmacist-Provided Services in the Primary Care Setting.

BACKGROUND: Pharmacists are increasingly fulfilling roles on primary care teams, yet business models for pharmacist services in these settings have not been optimized. This study describes how an ambulatory care pharmacy department implemented various billing methods to generate revenue for pharmacist services. OBJECTIVES: (1) Describe pharmacist-delivered billable and non-billable services; and (2) Assess the impact of various billing methods on the return-on-investment (ROI) for billable services. METHODS: This study was conducted from September 2016 to August 2017 in Virginia. Pharmacist time spent performing billable encounters using current procedural technology (CPT) codes (e.g., incident-to a physician, annual wellness visits) was calculated. Encounters eligible for the hospital-based facility (G0463) and chronic care management (CCM) codes were considered to be potentially billable services. The ROI was calculated for billable and potentially billable services. RESULTS: A total of 948.3 hours (0.46 full-time equivalents (FTE)), 17% of all clinical services, were billed using CPT codes. This resulted in a total revenue of $173,638.66. Missed revenue from not billing for the G0463 and CCM codes was $68,268.37. The cost of pharmacist services for 0.46 FTE was $78,613.08, resulting in a ROI for billed pharmacist services of 1.2:1. The ROI increased to 1.6:1 when considering potentially billable services. CONCLUSION: It is feasible to have a positive ROI for billable pharmacist services. To achieve a sustainable business model, there must be a high volume of billable services. G0463 and CCM codes are often underutilized, yet represent significant opportunities in revenue for pharmacist services and should be pursued.

Pulmonary Health Effects of Electronic Cigarettes: A Scoping Review.

BACKGROUND: There is global concern regarding the public health impact of electronic cigarettes (ECs). ECs are commonly promoted as safer than conventional cigarettes (CCs), however there is limited knowledge of the long-term health effects. This scoping review examined the pulmonary health effects of ECs reported in the literature from 2009 to 2019. METHOD: PubMed, CINAHL, and Science Direct databases were used. Search terms included "vaping, electronic nicotine delivery systems, electronic cigarettes, lung diseases, respiratory diseases, and pulmonary." Original research articles in English that used human subjects between January 1, 2009 and January 31, 2020 and reported pulmonary outcomes were included. RESULTS: Forty-five studies met the inclusion criteria. There were 14 (31.1%) randomized experimental, 7 (15.6%) nonrandomized experimental, 6 (13.3%) cohort, and 18 (40.0%) cross-sectional studies. Sixteen (35.6%) studies were conducted in the United States; the rest were conducted across 11 other countries. The total number of subjects was 1,465,292 and ages ranged from 12 to 99 years across studies. Eligible studies demonstrated an association between EC use and pulmonary symptoms, asthma and chronic obstructive pulmonary disease diagnosis and exacerbations. The degree of this association varied based on the use of additional tobacco products. EC use resulted in worse outcomes than nonsmoking, but resulted in improved outcomes when compared with CC use or dual use of CC and EC. CONCLUSION: Evidence indicates that EC use, especially dual use, leads to negative pulmonary effects and adverse outcomes. Education on the potential risks and publishing of EC ingredients on labels could help improve public health safety communication and reduce EC use.

"Without my medication, I'm a wreck": Photo-elicitation to explore medication use among people experiencing homelessness.

BACKGROUND: People experiencing homelessness (PEH) live with a high burden of chronic illness, functional and cognitive impairments, and serious mental illness. Many PEH are prescribed complex medication regimens to manage symptoms and improve health and functioning. However, medication use within the context of homelessness is complicated, and adherence is often suboptimal. OBJECTIVE: To document medication use within the context of homelessness and explore experiences of medication use among people experiencing homelessness (PEH). METHODS: This study used mixed methods including photo-elicitation interviews. Participants were given a digital camera and asked to take pictures of people, places, things, and situations that represented every day medication use. Participants were also asked to write down reasons for taking the pictures. After two weeks, participants returned the camera and notes. At a subsequent interview, the photographs and notes were reviewed and discussed. Demographic and health-related information was also collected for each participant. An interpretive description approach was used for qualitative data analysis. Quantitative data were analyzed using descriptive statistics in order to describe the sample. RESULTS: Seven PEH completed this study. Mean age was 45 years (SD = 11.3) and length of homelessness was 6.1 years (SD = 11.3). All reported multiple chronic conditions (≥2) and reported taking 6.6 (SD = 2.6) medications. Participants reported medication adherence barriers with mean score of 37 (SD = 5.5) on the ASK-12, a 12-item scale with a range of 12-60 (higher scores indicate more barriers). Qualitative analysis identified four categories: medication-related burdens, medication-related beliefs, connectedness, and stigmatizing encounters. CONCLUSIONS: Medication use among PEH is complex and cannot be considered separately from daily life or from struggles to meet basic needs. Multi-level interventions are needed to optimize medication use among PEH, and healthcare professionals including community pharmacists should reinforce beliefs that medication-related benefits outweigh the burdens and then tailor services to the context of homelessness.

Faith-based Health and Social Services for People Experiencing Homelessness in the United States: A Scoping Review of the Literature.

Across the U.S., faith communities play a crucial role in delivering services to people experiencing homelessness (PEH). However, factors influencing faith communities' provision of health and social services to PEH and related outcomes are unclear. The purpose of this scoping review of the literature, therefore, was to investigate the provision of health and social services for PEH by faith communities across the U.S.: how those services are coordinated, funded, and sustained, and associated outcomes. Eleven articles met inclusion criteria and were included in this review. Findings suggest that while faith communities provide critical services for PEH, further research is necessary in order to understand how, when, and with whom they work; how programs are funded and sustained; and outcomes associated with these services. We suggest that academic-community partnerships may enhance our understanding of faith-based services for PEH and increase capacity of faith communities for providing them.

GPS Mobile Health Intervention Among People Experiencing Homelessness: Pre-Post Study.

BACKGROUND: People experiencing homelessness are at risk for gaps in care after an emergency department (ED) or hospital visit, which leads to increased use, poor health outcomes, and high health care costs. Most people experiencing homelessness have a mobile phone of some type, which makes mobile health (mHealth) interventions a feasible way to connect a person experiencing homelessness with providers. OBJECTIVE: This study aims to investigate the accuracy, acceptability, and preliminary outcomes of a GPS-enabled mHealth (GPS-mHealth) intervention designed to alert community health paramedics when people experiencing homelessness are in the ED or hospital. METHODS: This study was a pre-post design with baseline and 4-month postenrollment assessments. People experiencing homelessness, taking at least 2 medications for chronic conditions, scoring at least 10 on the Patient Health Questionnaire-9, and having at least 2 ED or hospital visits in the previous 6 months were eligible. Participants were issued a study smartphone with a GPS app programmed to alert a community health paramedic when a participant entered an ED or hospital. For each alert, community health paramedics followed up via telephone to assess care coordination needs. Participants also received a daily email to assess medication adherence. GPS alerts were compared with ED and hospital data from the local health information exchange (HIE) to assess accuracy. Paired t tests compared scores on the Patient Health Questionnaire-9, Medical Outcomes Study Social Support Survey, and Adherence Starts with Knowledge-12 adherence survey at baseline and exit. Semistructured exit interviews examined the perceptions and benefits of the intervention. RESULTS: In total, 30 participants were enrolled; the mean age was 44.1 (SD 9.7) years. Most participants were male (20/30, 67%), White (17/30, 57%), and not working (19/30, 63%). Only 19% (3/16) of the ED or hospital visit alerts aligned with HIE data, mainly because of patients not having the smartphone with them during the visit, the smartphone being off, and gaps in GPS technology. There was a significant difference in depressive symptoms between baseline (mean 16.9, SD 5.8) and exit (mean 12.7, SD 8.2; t19=2.9; P=.009) and a significant difference in adherence barriers between baseline (mean 2.4, SD 1.4) and exit (mean 1.5, SD 1.5; t17=2.47; P=.03). Participants agreed that the app was easy to use (mean 4.4/5, SD 1.0, with 5=strongly agree), and the email helped them remember to take their medications (mean 4.6/5, SD 0.6). Qualitative data indicated that unlimited smartphone access allowed participants to meet social needs and maintain contact with case managers, health care providers, family, and friends. CONCLUSIONS: mHealth interventions are acceptable to people experiencing homelessness. HIE data provided more accurate ED and hospital visit information; however, unlimited access to reliable communication provided benefits to participants beyond the study purpose of improving care coordination.

"It's Time to Represent": shifting the paradigm to improve the quality of inputs into value assessment frameworks.

"It's Time to Represent" integrates 2 strategies that challenge the status quo to increase the diversity of populations that participate in research and address drivers of health disparities to better inform value assessment. The first, a community-engaged campaign, proposes to develop authentic, long-term partnerships with community members, their health care providers, and researchers to tailor recruitment and retention methods for underrepresented groups and hold researchers accountable for equitable selection of study participants. The second proposes to create an expectation for researchers to routinely collect patient-reported, actionable social determinants of health data to generate enhanced real-world evidence and thereby improve the quality of inputs utilized in value assessment frameworks. DISCLOSURE: No specific funding was received for this manuscript. The authors report no potential conflicts of interest.

Smartphone Technology to Empower People Experiencing Homelessness: Secondary Analysis.

BACKGROUND: In the United States, the number of people experiencing homelessness has continually increased over the last 3 years. Homelessness is associated with poor health, and people experiencing homelessness are often burdened with high rates of chronic and mental health conditions, functional limitations, and cognitive impairment. Despite the high burden of chronic illness and functional limitations, there is limited literature exploring self-management among homeless populations. OBJECTIVE: This study aims to investigate how access to smartphone technology facilitates self-management, including the attainment of social needs within the context of homelessness. METHODS: A secondary analysis of 33 exit interviews from 2 feasibility studies related to mobile health interventions among people experiencing homelessness was conducted. Iterative thematic analysis was used to identify themes representative of participants' experiences using smartphone technology. RESULTS: Collectively, participants revealed not only how the context of homelessness constrained their ability to engage in activities necessary to self-manage health and meet social needs but also how consistent and predictable access to the tools available through a smartphone changed their behaviors and outlook. The global theme of empowered by technology was identified and defined as how having a smartphone with a plan for unlimited text, calling, data, and transportation allowed participants to navigate homelessness and facilitated self-management. CONCLUSIONS: People experiencing homelessness used the tools on a smartphone to make decisions, take action, solve problems, and use the resources-skills necessary for fulfilling tasks required for effective self-management. Further, consistent access to smartphone technology and transportation empowered participants to meet the requirements for the attainment of social needs.

"It's Time to Represent": shifting the paradigm to improve the quality of inputs into value assessment frameworks.

"It's Time to Represent" integrates 2 strategies that challenge the status quo to increase the diversity of populations that participate in research and address drivers of health disparities to better inform value assessment. The first, a community-engaged campaign, proposes to develop authentic, long-term partnerships with community members, their health care providers, and researchers to tailor recruitment and retention methods for underrepresented groups and hold researchers accountable for equitable selection of study participants. The second proposes to create an expectation for researchers to routinely collect patient-reported, actionable social determinants of health data to generate enhanced real-world evidence and thereby improve the quality of inputs utilized in value assessment frameworks. DISCLOSURE: No specific funding was received for this manuscript. The authors report no potential conflicts of interest.