Storylines of family medicine XII: family medicine and the healthcare system.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'XII: Family medicine and the future of the healthcare system', authors address the following themes: 'Leadership in family medicine', 'Becoming an academic family physician', 'Advocare-our call to act', 'The paradox of primary care and three simple rules', 'The quadruple aim-melding the patient and the health system', 'Fit-for-purpose medical workforce', 'Universal healthcare-coverage for all', 'The futures of family medicine' and 'The 100th essay.' May readers of these essays feel empowered to be part of family medicine's exciting future.

Erratum: Toward standardization, harmonization, and integration of social determinants of health data: A Texas Clinical and Translational Science Award institutions collaboration - CORRIGENDUM.

[This corrects the article DOI: 10.1017/cts.2024.2.].

Storylines of family medicine X: standing up for diversity, equity and inclusion.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'X: standing up for diversity, equity and inclusion', authors address the following themes: 'The power of diversity-why inclusivity is essential to equity in healthcare', 'Medical education for whom?', 'Growing a diverse and inclusive workforce', 'Therapeutic judo-an inclusive approach to patient care', 'Global family medicine-seeing the world "upside down"', 'The inverse care law', 'Social determinants of health as a lens for care', 'Why family physicians should care about human rights' and 'Toward health equity-the opportunome'. May the essays that follow inspire readers to promote change.

Toward standardization, harmonization, and integration of social determinants of health data: A Texas Clinical and Translational Science Award institutions collaboration.

Introduction: The focus on social determinants of health (SDOH) and their impact on health outcomes is evident in U.S. federal actions by Centers for Medicare & Medicaid Services and Office of National Coordinator for Health Information Technology. The disproportionate impact of COVID-19 on minorities and communities of color heightened awareness of health inequities and the need for more robust SDOH data collection. Four Clinical and Translational Science Award (CTSA) hubs comprising the Texas Regional CTSA Consortium (TRCC) undertook an inventory to understand what contextual-level SDOH datasets are offered centrally and which individual-level SDOH are collected in structured fields in each electronic health record (EHR) system potentially for all patients. Methods: Hub teams identified American Community Survey (ACS) datasets available via their enterprise data warehouses for research. Each hub's EHR analyst team identified structured fields available in their EHR for SDOH using a collection instrument based on a 2021 PCORnet survey and conducted an SDOH field completion rate analysis. Results: One hub offered ACS datasets centrally. All hubs collected eleven SDOH elements in structured EHR fields. Two collected Homeless and Veteran statuses. Completeness at four hubs was 80%-98%: Ethnicity, Race; < 10%: Education, Financial Strain, Food Insecurity, Housing Security/Stability, Interpersonal Violence, Social Isolation, Stress, Transportation. Conclusion: Completeness levels for SDOH data in EHR at TRCC hubs varied and were low for most measures. Multiple system-level discussions may be necessary to increase standardized SDOH EHR-based data collection and harmonization to drive effective value-based care, health disparities research, translational interventions, and evidence-based policy.

Implementation of the Texas Community-Engaged Statewide Consortium for the Prevention of COVID-19.

The Community Engagement Alliance (CEAL) Against COVID-19 Disparities aims to conduct community-engaged research and outreach. This paper describes the Texas CEAL Consortium's activities in the first year and evaluates progress. The Texas CEAL Consortium comprised seven projects. To evaluate the Texas CEAL Consortium's progress, we used components of the RE-AIM Framework. Evaluation included estimating the number of people reached for data collection and education activities (reach), individual project goals and progress (effectiveness), partnerships established and partner engagement (adoption), and outreach and education activities (implementation). During the one-year period, focus groups were conducted with 172 people and surveys with 2107 people across Texas. Partners represented various types of organizations, including 11 non-profit organizations, 4 academic institutions, 3 civic groups, 3 government agencies, 2 grassroots organizations, 2 faith-based organizations, 1 clinic, and 4 that were of other types. The main facets of implementation consisted of education activities and the development of trainings. Key recommendations for future consortiums relate to funding and research logistics and the value of strong community partnerships. The lessons learned in this first year of rapid deployment inform ongoing work by the Texas CEAL Consortium and future community-engaged projects.

Community Health Workers as Trust Builders and Healers: A Cohort Study in Primary Care.

PURPOSE: Improving patients' self-care for chronic disease is often elusive in the context of social deprivation. We evaluated whether a practice-integrated community health worker (CHW) intervention could encourage effective long-term self-management of type 2 diabetes mellitus (T2DM). METHODS: This cohort study, in a safety-net primary care practice, enrolled patients with uncontrolled T2DM and psychosocial risk factors. Patients were identified through a practice diabetes registry or by clinicians' referrals. The CHWs engaged patients in trust building and sensemaking to understand their social context, identify goals, navigate health care, and connect to community resources. Primary outcome was progress through 3 prospectively defined stages of self-care: outreach (meeting face-to-face); stabilization (collaborating to address patients' life circumstances); and self-care generativity (achieving self-care competencies). Secondary outcomes were change in hemoglobin A1c (HbA1c) and need for urgent care, emergency department, or hospital visits. RESULTS: Of 986 participating patients, 27% remained in outreach, 41% progressed to stabilization, and 33% achieved self-care generativity. Repeated measures ANOVA demonstrates an overall decline in HbA1c, without group differences, through the 4th HbA1c measurement (mean follow-up 703 days). Beginning at the 5th HbA1c measurement (mean 859 days), the self-care generativity group achieved greater declines in HbA1c, which widened through the 10th measurement (mean 1,365 days) to an average of 8.5% compared with an average of 8.8% in the outreach group and 9.0% in the stabilization group (P = .003). Rates of emergency department and hospital visits were lower in the self-care generativity group. CONCLUSIONS: Practice-linked CHWs can sustainably engage vulnerable patients, helping them advance self-management goals in the context of formidable social disadvantage.

The Texas Community-Engagement Research Alliance Against COVID-19 in Disproportionately Affected Communities (TX CEAL) Consortium.

The coronavirus disease 2019 (COVID-19) pandemic requires urgent implementation of effective community-engaged strategies to enhance education, awareness, and inclusion of underserved communities in prevention, mitigation, and treatment efforts. The Texas Community-Engagement Alliance Consortium was established with support from the United States' National Institutes of Health (NIH) to conduct community-engaged projects in selected geographic locations with a high proportion of medically underserved minority groups with a disproportionate burden of COVID-19 disease and hospitalizations. The purpose of this paper is to describe the development of the Consortium. The Consortium organized seven projects with focused activities to address COVID-19 clinical and vaccine trials in highly affected counties, as well as critical statewide efforts. Five Texas counties (Bexar, Dallas, Harris, Hidalgo, and Tarrant) were chosen by NIH because of high concentrations of underserved minority communities, existing community infrastructure, ongoing efforts against COVID-19, and disproportionate burden of COVID-19. Policies and practices can contribute to disparities in COVID-19 risk, morbidity, and mortality. Community engagement is an essential element for effective public health strategies in medically underserved minority areas. Working with partners, the Consortium will use community engagement strategies to address COVID-19 disparities.

Same-Day Correlates and Prior-Day Predictors of Couples' Violent Behaviors Based upon Partners' Daily Reports.

Although previous research identified predictors of violent events within violent heterosexual couples, findings were limited to the woman's reports, to her perceptions; his assessments were not obtained. This exploratory study was conducted to gain understanding of proximal predictors of violence assessed in "real-time" from the perspective of both partners. Fifteen adult heterosexual couples in which the woman reported experiencing partner violence in the prior 30 days were enrolled in a primary care clinic. Each partner provided separate daily telephone reports for eight weeks via an automated Interactive Voice Response (IVR), concerning the previous day's violence, alcohol use, stressors, emotional reactions and concerns for children. Same-day correlates were determined by Pearson correlations while prior-day predictors were identified via vector autoregression. Same-day correlations show that men's violence was associated with almost every other variable while women's violence correlated with men's violence, men's drug use, women's alcohol use, anger, closeness, hassles, and all men's negative feelings. Using prior-day predictors, men's violence was related to feelings (primarily hers), but women's violence was more dependent upon feelings of both of them as well as women's prior-day violence and alcohol use. Men's violence was dependent upon their partners' prior-day feelings and the men's lack of concern about effects of violence on children. Women's violence was also dependent upon women's prior-day feelings, as well as women's violence, alcohol use, marital closeness, and men's concern for children. Although the co-occurrence of men's and women's violence has been seen before, in this study only women's violence was linked to alcohol use.

Work-related and personal predictors of COVID-19 transmission: evidence from the UK and USA.

OBJECTIVE: To develop evidence of work-related and personal predictors of COVID-19 transmission. SETTING AND RESPONDENTS: Data are drawn from a population survey of individuals in the USA and UK conducted in June 2020. BACKGROUND METHODS: Regression models are estimated for 1467 individuals in which reported evidence of infection depends on work-related factors as well as a variety of personal controls. RESULTS: The following themes emerge from the analysis. First, a range of work-related factors are significant sources of variation in COVID-19 infection as indicated by self-reports of medical diagnosis or symptoms. This includes evidence about workplace types, consultation about safety and union membership. The partial effect of transport-related employment in regression models makes the chance of infection over three times more likely while in univariate analyses, transport-related work increases the risk of infection by over 40 times in the USA. Second, there is evidence that some home-related factors are significant predictors of infection, most notably the sharing of accommodation or a kitchen. Third, there is some evidence that behavioural factors and personal traits (including risk preference, extraversion and height) are also important. CONCLUSIONS: The paper concludes that predictors of transmission relate to work, transport, home and personal factors. Transport-related work settings are by far the greatest source of risk and so should be a focus of prevention policies. In addition, surveys of the sort developed in this paper are an important source of information on transmission pathways within the community.

Bootstrapping implementation research training: A successful approach for academic health centers.

Demand for building competencies in implementation research (IR) outstrips supply of training programs, calling for a paradigm shift. We used a bootstrap approach to leverage external resources and create IR capacity through a novel 2-day training for faculty scientists across the four Texas Clinical & Translational Science Awards (CTSAs). The Workshop combined internal and external expertise, targeted nationally established IR competencies, incorporated new National Institutes of Health/National Cancer Institute OpenAccess online resources, employed well-known adult education principles, and measured impact. CTSA leader buy-in was reflected in financial support. Evaluation showed increased self-reported IR competency; statewide initiatives expanded. The project demonstrated that, even with limited onsite expertise, it was possible to bootstrap resources and build IR capacity de novo in the CTSA community.

Is Perceived Need for Action Among Women in Violent Relationships Nonlinear and, If So, Why?

Despite the prevalence and impact of partner violence, we understand little about women's action taking except that it seems an unpredictable, nonlinear process. This article determines the degree of nonlinearity in perceived need for help, legal action, or leaving among women in violent relationships. The participants included 143 women who experienced violence in the previous month, enrolled from six primary care clinics. Baseline surveys assessed background characteristics and factors which may affect perceived need for action. Multiple times series assessments of violence and need for action were collected daily for 8 weeks via telephone Interactive Voice Response. Measures of nonlinearity of violence, perceived need for help, legal action, and leaving were computed. Repeated measures ANOVA assessed differences across measures of nonlinearity. To identify factors contributing to nonlinearity, staged multiple regression assessed the relationship between nonlinearity measures and outcomes. Ninety-three women completed sufficient time series for nonlinearity assessment. Measures of nonlinearity were lower for need for legal action compared with needs for help and leaving. Regression analysis suggested that isolation, social networks, and lack of awareness contribute to nonlinearity. Women's perceived need for legal action and its level of nonlinearity were lowest compared with those of help seeking and leaving. Although its relative linearity suggests that the need for legal action may be the most predictable, its lower mean rating suggests that legal action is a low priority. Although need for help and leaving are of higher priorities, their nonlinearity suggests that intervention will not yield predictable results.

He Said, She Said: Comparing Men's and Women's Descriptions of Men's Partner Violence.

More than one in three women and one in four men in the United States report victimization by intimate partner violence. Women and men often disagree about the frequency or severity of violent acts, and researchers have proposed various reasons for discordant reports. Using daily surveys and qualitative interviews, we compared men's and women's reports about men's partner aggression and examined language they used to describe their experiences. Fifteen heterosexual couples in violent relationships completed an 8-week study that involved daily telephone surveys about violent behaviors and household environment; baseline and end-of-study surveys addressing predictors and outcomes of violence; and qualitative end-of-study interviews to provide perspective about their relationships. Most participants were Latinos with low income. Relationship length was 5.5 years, median. In daily surveys, both partners reported similar frequencies of men's physical violence (4% of days), but men reported more physical violence by women than women did (8% vs. 3% of days). The qualitative analysts compared men's and women's accounts of male-to-female violence and observed gender-specific variations in style of reporting. Men used indirect language to describe their violent behavior, implied definitions of abuse, and justified their aggression. These findings have implications for clinical guidelines to screen and intervene with victims and perpetrators of intimate partner violence in primary care and emergency settings. Future research should focus on perpetrators of violence and examine effective ways for health care providers to identify and manage their care.

Modeling Women's Need For Action in Violent Relationships.

We are beginning to understand that intimate partner violence (IPV) and women's decision-making about that violence are nonlinear phenomena. IPV and decision-making are influenced by variables feedforwarding upon themselves with multiple interconnected predictors and circularly causal relationships. Computer models can help us gain a systems perspective on these relationships and enable hypothesis-testing without engendering risk to women in these relationships. The purpose of this study was to develop a mathematical model of women's decision-making concerning her violent relationship and assess the impact of random stress and her controllable behaviors on violence and decision-making. An agent-based model was created using data from couples with history of violence, based upon results of multiple time series of partner violence. To explore factors that may alter model results, eight continuous variable parameters were created based upon significant (p ≤ .05) but discrepant (opposite directions) results from two prior time series studies. Overall, 13 unique patterns of violence in five categories were identified, but none of these categories included his violence alone without some additional influence (i.e., marital distance leading to marital distance the following day). To assess the potential impact that random stress and behaviors under her control (arguments, forgiveness, alcohol use, violence) could have on need-for-action and actions taken, the effects of variable parameter settings on these outcomes were also assessed. While random stress had little effect on outcomes, her interventions could have an impact but were pattern-specific. Her daily participation in arguments correlated with more violence. The need-for and actually taking action were at times independent of each other. This mathematical model yielded results that generally involved her violence with or without his violence. Thus, modeling partner violence and women's decision-making is possible, yielding diverse patterns. However, the complexity of interdependent predictors unique to each relationship means that targeted interventions will need to be couple-specific.

Complex Relationship Between Daily Partner Violence and Alcohol Use Among Violent Heterosexual Men.

Although alcohol use and partner violence are consistently associated, the nature of the alcohol-violence relationship is still unclear. The purpose of this pilot study was to use longitudinal daily assessments of male partners' alcohol use and violent events to identify the nature of the alcohol-violence relationship, employing both linear and nonlinear analyses. The participants were 20 adult heterosexual couples of whom the woman reported experiencing partner violence in the prior 30 days. Each partner provided a separate daily telephone report for 8 weeks via an automated interactive voice response (IVR), concerning the previous day's violence, alcohol use, stressors, emotional reactions, and concerns for children. Individual IVR databases were merged to form a combined couple's IVR time series. Time series were analyzed using graphic, linear, and nonlinear methods. Graphic analysis using state space grids found no consistent pattern across couples. Similarly, linear analysis using same-day cross-correlation and prior-day beta statistics found no significant group-level alcohol-violence relationship. Using cross-approximate entropy statistics and differential structural equation modeling, no nonlinear relationships between alcohol use and violence were noted either. Whether applying linear or nonlinear analytic methods, there is no group-level relationship between alcohol use by male perpetrators and their violent acts. The implications are significant. First, the alcohol-violence relationship may differ among subgroups. Second, couples need to be assessed thoroughly to determine their unique relationship with alcohol use, so that couple-specific interventions can be designed. Third, if perpetrators believe that their violence is facilitated by their alcohol use, then alcohol reduction should be encouraged despite any evidence suggesting a different alcohol-violence relationship. Finally, the accepted alcohol-causes-violence belief held by many providers needs to be reconsidered. Because the nature of the alcohol-violence relationship varies considerably across couples, clinicians should seek to understand their unique relationship applying across-the-board management approaches.

Effect of Incorporating Catastrophic Equations into an Agent-Based Model of Women's Action-Taking in Violent Relationships.

Based upon multiple time series studies, an agent-based model (ABM) of women's decision-making related to partner violence was developed. However, help-seeking, legal action and leaving could be modeled as catastrophic phenomena, but catastrophic effects were not included in this prior ABM. The purpose of this study was to incorporate cusp catastrophe equations into the prior ABM to determine the impact upon her action-taking. Building upon this prior ABM of women's decision-making, we added cusp-related equations and compared resultant patterns and impacts of stress and interventions against those of the prior ABM. To assess the potential impact that random stress and her behavior could have on violence and stalking, the effect of variable parameter settings of these factors were assessed. Adding cusp equations to the prior ABM resulted in more legal action-taking for most of these patterns, many showing the effects of the bifurcation variables, and more women leaving in half of the patterns, but at the expense of increasing instability and more distortion effects. However, help-seeking was most impacted by possible interventions. In conclu-sion, adding cusp equations to the model had significant effects on modeling action-taking, especially for legal action and leaving while affecting the impact of interventions on help-seeking.

Improving Equity Through Primary Care: Proceedings of the 2019 Toronto International Conference on Quality in Primary Care.

Health equity allows people to reach their full health potential and receive high-quality care that is appropriate for them and their needs, no matter where they live, what they have, or who they are. It is a core element of quality in health care. Around the world, there are many efforts to improve equity through primary care. In order to advance these efforts, it is important to share successes and challenges. Building on our work with international stakeholders to identify key primary care research priorities, we organized the Toronto International Conference on Quality in Primary Care that was held on November 16, 2019. Participants from 8 countries took part. Key recommendations included the establishment of continuous relationships between providers and patients over time, relationships between providers in the health and social sectors, and resources supported proportionally to patient need. Solutions must be generated using team-based approaches that explicitly include people with who have experienced discrimination. Progress will require confronting structural determinants including racism, capitalism, and colonialism. Conference participants suggested practical solutions, such as developing a public transportation program for rural residents to improve community building and the ability to attend medical appointments, and identifying patients who have recently missed clinic visits that may benefit from additional care. These approaches will need to be evaluated through high-quality research and quality improvement, with a knowledge translation that facilitates sustainability and expansion across settings.

Is Readiness to Take Action Among Women in Violent Relationships a Catastrophic Phenomenon?

Taking action among women in violent relationships appears to involve sudden changes and reversals after periods of building stress, suggesting that decision making is a "catastrophic" phenomenon. This study sought to determine whether readiness-to-change is best modeled as a cusp catastrophic (CCM) phenomenon among women in violent relationships. A total of 143 women who experienced violence in the previous month completed baseline and end-of-study interviews assessing her hope, coping strategies, social network, and readiness-for-action (seeking help, taking legal action, and leaving) concerning the violence. Daily assessments of his violent behavior, forgiveness sought and given, and her perceived need-for-action were collected via telephone Interactive Voice Response for 8 weeks. Using regression analysis, the impact of factor-analyzed asymmetry (violence burden) and bifurcation (hope and cope, support, forgiveness, and number of children) variables on the outcomes (readiness-for-help, legal action, and leaving) was modeled, comparing the CCM against linear models to determine which model accounts for the most variance in each outcome. Cusp catastrophe models for all three actions accounted for more variance than either linear model comparison, but violence burden was only relevant to readiness-for-help and different bifurcation variables were at work for each action. While forgiveness was an important bifurcation factor in readiness-for-help and number of children served as the bifurcation factor for readiness-for-legal-action, readiness-to-leave was more complex with both number of children and hope-and-cope as bifurcation factors. Not only should we expect sudden changes in readiness but efforts to facilitate decision making should focus on addressing the bifurcation factors that may distort her interpretation of reality.

Primary Care and Food Bank Collaboration to Address Food Insecurity: A Pilot Randomized Trial.

Food insecurity is common in the United States and linked to poor control of conditions influenced by diet. We conducted a pilot randomized trial to test whether a novel partnership between a primary care practice and a municipal food bank would improve control of type 2 diabetes among patients with food insecurity. Participants received food bank produce delivered twice monthly to the practice site, brief teaching from a food bank dietitian, and home-based education from a community health worker. After 6 months, glycosylated hemoglobin decreased (absolute change) by 3.1% in the intervention group vs 1.7% in the control group (P = .012). Scores on Starting the Conversation-Diet, a brief dietary measure, improved in the intervention group by 2.47 on a 14-point scale (P < .001). Body mass indexes (BMIs) were unchanged. In this early-stage study, onsite collaboration between primary care and a regional food bank generated clinically meaningful reductions in HbA1c and improvements in diet.

Psychometrics of the Violence Nonlinear Dynamics Scale.

OBJECTIVE: The trajectory of daily partner violence generally demonstrates nonlinear dynamics, and this nonlinearity is important to patient outcomes, as it is sometimes a stronger predictor of outcomes than violence frequency or severity. However, measurement of such dynamics is difficult, requiring complete time series data of sufficient length to yield stable measures. The purpose of this study was to develop a pencil-and-paper instrument to estimate violence nonlinearity and assess its psychometrics. METHODS: Adult women (N = 143) who experienced violence in the previous month were enrolled from 6 primary care clinics. Baseline surveys assessed factors known to correlate with nonlinearity (partner's control strategies, violence appraisal, hope, social support, coping style) and violence dynamics using a 30-item instrument based on traditional characteristics of complex adaptive systems. Participants completed daily assessments of the previous day's violence using interactive voice response via telephone for 8 weeks, with data collection occurring between August 2013 and March 2015. Three different measures of nonlinearity were computed: LZ complexity (algorithmic complexity), approximate entropy (lack of regularity), and Lyapunov exponent (sensitivity to initial conditions). RESULTS: Using factor analysis and reliability measures, the final 10-item Violence Nonlinearity Dynamics Scale (VNDS) was identified. The VNDS was found to have both internal consistency (0.817) and split-half reliability (0.796). In addition, the instrument demonstrated concurrent (correlating with both the combined nonlinearity factor score [r = 0.267] and Grassberger-Procaccia entropy [r = 0.338]) and construct (correlating with 9 of 13 previously identified nonlinearity correlates) validity. CONCLUSIONS: The VNDS has both reliability and validity and could facilitate the inclusion of nonlinearity assessment in both intimate partner violence research and clinical work.

Agent-Based Modeling of Day-to-Day Intimate Partner Violence.

The purpose of this study was to develop a mathematical model of mutual partner violence and assess impact of her controllable behaviors on reducing violence. An agent-based model was created of couples with history of violence based upon results of two multiple time series studies of partner violence. To explore factors that may alter model results, eight continuous variable parameters were created based upon significant (p=.05) but discrepant (opposite directions) results from previous studies. To assess the potential impact that random stress and her behavior (arguments, forgiveness, alcohol use, violence) could have on violence and stalking, the impact of variable parameter settings of these factors were also assessed. The model identified 18 unique patterns were observed, grouped into five general categories. Added random stress contributed to his violence in only two patterns. Although avoiding participation in arguments had no effect, her forgiveness and elimination of alcohol use often reduced her violence only. However, consistent violence or nonviolence on her part sometimes affected his violence and stalking. In conclusion, while increasing forgiveness and reducing alcohol intake could reduce her violence, they generally had little effect on his. However, if she eliminated her violence, it could eliminate his violence and stalking in some situations.