Cultural and co-designed principles for developing a Maori kaumatua housing village to address health and social wellbeing.

BACKGROUND: The current study is a case study of a Maori (Indigenous people of New Zealand) organisation and their developmental processes in creating a kaumatua (older people) housing village for health and social wellbeing. This study identifies how a set of established co-design and culturally-centred principles were enacted when creating and developing the village. METHOD: A mixed-method concurrent design was used in creating the case with interviews (n = 4), focus groups (N = 4 with 16 total participants) and survey questionnaires (n = 56) involving kaumatua and organisation members. RESULTS: Survey results illustrate that suitable and affordable housing are associated with self-rated health, loneliness, and life satisfaction. The primary purpose of the housing village was to enable kaumatua to be connected to the marae (community meeting house) as part of a larger vision of developing intergenerational housing around the marae to enhance wellbeing. Further, key themes around visioning, collaborative team and funding, leadership, fit-for-purpose design, and tenancy management were grounded in cultural elements using te ao Maori (Maori worldview). CONCLUSION: This case study illustrates several co-design and culturally-centred principles from a previously developed toolkit that supported the project. This case study demonstrates how one community enacted these principles to provide the ground for developing a housing project that meets the health and social wellbeing of kaumatua.

Tuakana-teina peer education programme to help Maori elders enhance wellbeing and social connectedness.

BACKGROUND: There are significant inequities between Maori (Indigenous people) and non-Maori in ageing outcomes. This study used a strengths-based approach based on the key cultural concept of mana motuhake (autonomy and self-actualisation) to develop a tuakana-teina (literally older sibling-younger sibling) peer education programme to assist kaumatua (elders) in addressing health and social needs. The purpose of this study was to test the impact on those receiving the programme. Three aims identify the impact on outcomes, resources received and the cost effectiveness of the programme. METHODS: Five Kaupapa Maori (research and services guided by Maori worldviews) iwi (tribe) and community providers implemented the project using a partnership approach. Tuakana (peer educators) had up to six conversations each with up to six teina (peer learners) and shared information related to social and health services. A pre- and post-test, clustered staggered design was the research design. Participants completed a baseline and post-programme assessment of health and mana motuhake measures consistent with Maori worldviews. Open-ended questions on the assessments, five focus groups, and four individual interviews were used for qualitative evaluation. FINDINGS: A total of 113 kaumatua were recruited, and 86 completed the programme. The analysis revealed improvements in health-related quality of life, needing more help with daily tasks, life satisfaction, paying bills and housing problems. Qualitative results supported impacts of the programme on mana motuhake and hauora (holistic health) through providing intangible and tangible resources. Cost-effectiveness analysis showed that the intervention is cost effective, with a cost per QALY of less than the conventional threshold of three times GDP per capita. CONCLUSIONS: A culturally-resonant, strengths-based programme developed through a participatory approach can significantly improve health and social outcomes in a cost-effective way. TRIAL REGISTRY: Clinical trial registry: Trial registration: (ACTRN12620000316909). Prospectively registered 06/03/2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379302&isClinicalTrial=False .

Enhancing health outcomes for Maori elders through an intergenerational cultural exchange and physical activity programme: a cross-sectional baseline study.

Background: The study offers baseline data for a strengths-based approach emphasizing intergenerational cultural knowledge exchange and physical activity developed through a partnership with kaumatua (Maori elders) and kaumatua service providers. The study aims to identify the baseline characteristics, along with correlates of five key outcomes. Methods: The study design is a cross-sectional survey. A total of 75 kaumatua from six providers completed two physical functioning tests and a survey that included dependent variables based in a holistic model of health: health-related quality of life (HRQOL), self-rated health, spirituality, life satisfaction, and loneliness. Results: The findings indicate that there was good reliability and moderate scores on most variables. Specific correlates included the following: (a) HRQOL: emotional support (ß = 0.31), and frequent interaction with a co-participant (ß = 0.25); (b) self-rated health: frequency of moderate exercise (ß = 0.32) and sense of purpose (ß = 0.27); (c) spirituality: sense of purpose (ß = 0.46), not needing additional help with daily tasks (ß = 0.28), and level of confidence with cultural practices (ß = 0.20); (d) life satisfaction: sense of purpose (ß = 0.57), frequency of interaction with a co-participant (ß = -0.30), emotional support (ß = 0.25), and quality of relationship with a co-participant (ß = 0.16); and (e) lower loneliness: emotional support (ß = 0.27), enjoyment interacting with a co-participant (ß = 0.25), sense of purpose (ß = 0.24), not needing additional help with daily tasks (ß = 0.28), and frequency of moderate exercise (ß = 0.18). Conclusion: This study provides the baseline scores and correlates of important social and health outcomes for the He Huarahi Tautoko (Avenue of Support) programme, a strengths-based approach for enhancing cultural connection and physical activity.

Exploring theoretical mechanisms of community-engaged research: a multilevel cross-sectional national study of structural and relational practices in community-academic partnerships.

BACKGROUND: Community-Based Participatory Research (CBPR) is often used to address health inequities due to structural racism. However, much of the existing literature emphasizes relationships and synergy rather than structural components of CBPR. This study introduces and tests new theoretical mechanisms of the CBPR Conceptual Model to address this limitation. METHODS: Three-stage online cross-sectional survey administered from 2016 to 2018 with 165 community-engaged research projects identified through federal databases or training grants. Participants (N = 453) were principal investigators and project team members (both academic and community partners) who provided project-level details and perceived contexts, processes, and outcomes. Data were analyzed through structural equation modeling and fuzzy-set qualitative comparison analysis. RESULTS: Commitment to Collective Empowerment was a key mediating variable between context and intervention activities. Synergy and Community Engagement in Research Actions were mediating variables between context/partnership process and outcomes. Collective Empowerment was most strongly aligned with Synergy, while higher levels of Structural Governance and lower levels of Relationships were most consistent with higher Community Engagement in Research Actions. CONCLUSIONS: The CBPR Conceptual Model identifies key theoretical mechanisms for explaining health equity and health outcomes in community-academic partnerships. The scholarly literature's preoccupation with synergy and relationships overlooks two promising practices-Structural Governance and Collective Empowerment-that interact from contexts through mechanisms to influence outcomes. These results also expand expectations beyond a "one size fits all" for reliably producing positive outcomes.

Enhancing Well-Being and Social Connectedness for Maori Elders Through a Peer Education (Tuakana-Teina) Programme: A Cross-Sectional Baseline Study.

Background: Maori kaumatua (elders) face stark health and social inequities compared to non-Maori New Zealanders. The tuakana-teina (older sibling-younger sibling) peer education programme is a strengths-based approach to enhance well-being and social connectedness. The purpose of this study is to present the baseline data from this programme and identify correlates of well-being outcomes. Method: Participants included 128 kaumatua who completed a self-report survey about health-related quality of life, spirituality, social connection and loneliness, life satisfaction, cultural identity and connection, elder abuse, health service utilisation and demographics. Findings: Multiple regression models illustrated the following correlates of outcomes: (a) self-rated health: needing more help with daily tasks (ß = -0.36) and housing problems (ß = -0.17); (b) health-related quality of life: needing more help with daily tasks (ß = -0.31), housing problems (ß = -0.21), and perceived autonomy (ß = 0.19); (c) spiritual well-being: understanding of tikanga (cultural protocols) (ß = 0.32) and perceived autonomy (ß = 0.23); (d) life satisfaction: social support (ß = 0.23), sense of purpose (ß = 0.23), cultural identity (ß = 0.24), trouble paying bills (ß = -0.16), and housing problems (ß = -0.16); (e) loneliness: elder abuse (ß = 0.27), social support (ß = -0.21), and missing pleasure of being with whanau (extended family) (ß = 0.19). Conclusions: Key correlates for outcomes centred on social support, housing problems, cultural connection and perceived autonomy. These correlates are largely addressed through the programme where tuakana/peer educators provide support and links to social and health services to teina/peer recipients in need. This study illustrates needs and challenges for kaumatua, whilst the larger programme represents a strengths-based and culturally-centred approach to address health issues related to ageing in an Indigenous population.

Scales of Practices and Outcomes for Community-Engaged Research.

Despite the growth of research on community-engaged research (CEnR), recent reviews suggest there has been limited development of validated scales to measure key contexts, mechanisms, and outcomes, impairing testing and refinement of theoretical models. The purpose of this study is to present the psychometric properties of scales from the Engage for Equity (E2) project, stemming from a long-term research partnership examining community-engaged research projects. This study used a three-stage, cross-sectional format: (a) a sampling frame of 413 CEnR projects was identified; (b) 210 principal investigators completed a project-level survey and nominated partners for another survey; (c) 457 investigators and partners completed a survey about project contexts, processes, interventions, and outcomes. Factorial validity was established through confirmatory factor analysis supporting seven scales: contextual capacity, commitment to collective empowerment, relationships, community engagement in research actions, synergy, partner and partnership transformation, and projected outcomes. Convergent validity was established through examining covariances among the scales. This study largely yielded results consistent with a previous psychometric study of related measures, while demonstrating improved ceiling effects of the items and refined conceptualization of core theoretical constructs.

Obesity and health care interventions: Substantiating a multi-modal challenge through the lens of grounded theory.

ISSUE ADDRESSED: One of the biggest concerns for human health in the 21st century is the ever-increasing rate of obesity and its associated budgetary implications for publicly funded health care service provisioning. This study at the outset explores the multifaceted nature of food-related consumption choices and outcomes of obesity, and later offers suggestions to improve the existing interventional strategies to curtail the epidemic. METHODS: A total of 24 participants were recruited through poster invitations placed around the greater metropolitan area of Auckland, New Zealand. Participants shared their health care intervention program experiences through in-depth, semi-structured interviews. Data were analysed in keeping with traditions of constructivist grounded theory. FINDINGS: Analysis revealed various concurrent individually acting and ecologically mediated processes which led to obesogenic outcomes as a result of social actors' (participants) engagement in acts of (food-related) consumption practices. CONCLUSIONS: This study helps to illustrate the underlying, multifaceted processes that lead to obese individuals feeling defeated or disempowered and categorically willing, yet unable to bring about healthy changes in their lives. We hope this study will prompt health care practitioners to take a holistic approach while conceiving and deploying health care intervention programs. SO WHAT?: Current health care interventional programs are not achieving optimum solutions for those in need. All future programs need to acknowledge the roles played by an individual, as well as ecological factors, while deploying client-centric intervention solutions. Perhaps these programs are in need of a team-based approach to offer a truly "wrap-around" service provisioning strategy, rather than the traditional one-on-one consultative approaches in use at current times.

Perceptions of co-designing health promotion interventions with Indigenous communities in New Zealand.

Health inequities among Indigenous and non-Indigenous communities are well documented and the research literature includes robust discussions about innovative ways to reduce inequities including co-design. Co-designing health promotion interventions with Indigenous communities presents many benefits and challenges for researchers, health professionals and communities involved in the process. The purpose of this study was to identify the facilitators and barriers of co-designing a health promotion intervention with Maori communities. Additionally, this study considers a specific Maori co-design framework, He Pikinga Waiora (HPW). HPW is a participatory approach to creating interventions emphasizing community engagement, systems thinking and centred on Kaupapa Maori (an approach grounded in Maori worldviews). The research design for this study was Kaupapa Maori. Participants (n = 19) in this study were stakeholders in the New Zealand health sector. Participants were interviewed using an in-depth, semi-structured protocol. Thematic analysis was employed to analyse the data. Facilitators for co-designing health promotion interventions with Maori communities were collaboration and community voice. Barriers identified were mismanaged expectations and research constraints. Finally, facilitators for the HPW framework included providing clear guidelines and being grounded in Maori perspectives, while barriers included limited concrete case studies, jargon and questions about sustainability. Collaboration and inclusion of community voice supports the development of more effective co-design health promotion interventions within Maori communities which may address health inequities. The HPW framework offers clear guidelines and Maori perspectives which may assist in the development of effective co-design health promotion interventions, although areas for improvement were suggested.

The sustainability of the New Zealand radiation therapy workforce: Factors that influence intent to leave the workplace and profession.

INTRODUCTION: The demand for radiation therapy services in New Zealand is growing due to an increasing and ageing population. The radiation therapist (RT) workforce is currently in a vulnerable state and this study aimed to understand RT perceptions on intent to remain in both the workplace and profession. Understanding factors that contribute to satisfaction and retention are important for the development of strategies by healthcare leaders to improve workforce sustainability. MATERIALS AND METHODS: All current practising RTs were invited via email link to complete an online survey. Multivariate regression models were used to investigate any impact of demographic, workplace and professional variables on intent to remain in the workplace and intent to leave the profession. RESULTS: Three hundred and sixty two (91% response rate) RTs completed the survey. Key findings include: a) 33% are thinking of leaving their current workplace with 31% of these intending to leave within the next 12 months; b) 35% intend to change careers before they retire; and c) 25% indicated they would leave the profession if they could. Workplace satisfaction, being challenged and a lack of career development opportunities were common factors that influence intention to leave both the workplace and profession. CONCLUSIONS: Strategies to ensure the sustainability of the RT workforce in New Zealand need to focus on developing a robust framework for career development including advanced practice opportunities that challenge RTs and ensuring workplaces create an environment that promote a sense of pride, camaraderie and flexibility in how they operate.

Kaumatua Mana Motuhake Poi: a study protocol for enhancing wellbeing, social connectedness and cultural identity for Maori elders.

BACKGROUND: The Aotearoa New Zealand population is ageing accompanied by health and social challenges including significant inequities that exist between Maori and non-Maori around poor ageing and health. Although historically kaumatua (elder Maori) faced a dominant society that failed to realise their full potential as they age, Maori culture has remained steadfast in upholding elders as cultural/community anchors. Yet, many of today's kaumatua have experienced 'cultural dissonance' as the result of a hegemonic dominant culture subjugating an Indigenous culture, leading to generations of Indigenous peoples compelled or forced to dissociate with their culture. The present research project, Kaumatua Mana Motuhake Poi (KMMP) comprises two interrelated projects that foreground dimensions of wellbeing within a holistic Te Ao Maori (Maori epistemology) view of wellbeing. Project 1 involves a tuakana-teina/peer educator model approach focused on increasing service access and utilisation to support kaumatua with the greatest health and social needs. Project 2 focuses on physical activity and cultural knowledge exchange (including te reo Maori--Maori language) through intergenerational models of learning. METHODS: Both projects have a consistent research design and common set of methods that coalesce around the emphasis on kaupapa kaumatua; research projects led by kaumatua and kaumatua providers that advance better life outcomes for kaumatua and their communities. The research design for each project is a mixed-methods, pre-test and two post-test, staggered design with 2-3 providers receiving the approach first and then 2-3 receiving it on a delayed basis. A pre-test (baseline) of all participants will be completed. The approach will then be implemented with the first providers. There will then be a follow-up data collection for all participants (post-test 1). The second providers will then implement the approach, which will be followed by a final data collection for all participants (post-test 2). DISCUSSION: Two specific outcomes are anticipated from this research; firstly, it is hoped that the research methodology provides a framework for how government agencies, researchers and relevant sector stakeholders can work with Maori communities. Secondly, the two individual projects will each produce a tangible approach that, it is anticipated, will be cost effective in enhancing kaumatua hauora and mana motuhake. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry ( ACTRN12620000316909 ). Registered 6 March 2020.

Personal Outcomes in Community-based Participatory Research Partnerships: A Cross-site Mixed Methods Study.

Community-based participatory research (CBPR) has been embraced by diverse populations to address health inequities within their communities. CBPR has been shown to produce favorable health outcomes, but little is known about personal outcomes (e.g., individual growth and capacities) resulting from the direct involvement in a CBPR partnership. We empirically examine which CBPR partnerships' processes and practices are associated with personal outcomes. We hypothesize that higher levels of collaborative approaches and adherence to CBPR principles and practices would be associated with personal outcomes. Based on a national cross-site CBPR study, Research for Improved Health, we utilized mixed-method data from a comprehensive community-engagement survey (N = 450) and seven in-depth case studies to explore the hypothesized relationships. Our multivariate mixed-effects model revealed the importance of various partnering practices. Relationship dynamics emerged as key predictors including the following: respect in the partnership, voice and influence in decision-making among partners, and stewardship. Qualitative findings highlighted individual, partnership, and community-level impacts, within and beyond the partnership. Our findings have implications for CBPR best practices and highlight the potential role of personal outcomes for partnerships' sustainability, long-term outcomes, and health equity research.

Kaumatua Mana Motuhake: peer education intervention to help Maori elders during later-stage life transitions.

BACKGROUND: Aotearoa/New Zealand has a population that is ageing and there are challenges to health and social outcomes related to related to key life transitions (e.g., retirement, change in health conditions, loss of spouse). Further, there are significant inequities between Maori (Indigenous people) and non-Maori in ageing outcomes. The purpose of this study was to test the impacts and cost effectiveness of a tuakana/teina (peer education) intervention on kaumatua (elders) receiving the intervention. This study was framed by a strengths-based approach based on the key cultural concept of mana motuhake (autonomy and self-actualisation). METHODS: This study was grounded in principles of Kaupapa Maori and community-based participatory research to bring together a diverse group of stakeholders to co-develop and co-evaluate the intervention. The intervention had tuakana (peer educators) having conversations with up to six teina (recipients) and providing information related to health and social services. The research design was a pre- and post-test, clustered staggered design. Participants completed a baseline assessment of health and mana motuhake measures consistent with Maori worldviews along with two follow-up assessments (one after the first intervention group completed its activities and a second after the second intervention group completed its activities). Additionally, five focus groups and open-ended questions on the assessments were used to provide qualitative evaluation. FINDINGS: A total of 180 kaumatua were recruited to the intervention with 121 completing it. The analysis revealed improvements over time in the expected direction on most of the variables. However, only three of the variables had statistically significant intervention effects: received support, tribal identity, and trouble paying bills. Qualitative results supported impacts of the intervention on mana motuhake, social connectedness, and tangible/information support related to services. Cost-effectiveness analysis showed that the intervention is cost effective, with a cost per QALY of less than the conventional threshold of three times gross domestic product per capita. CONCLUSIONS: The findings support the relevancy and importance of kaumatua knowledge to create a strengths-based approach to improve health and social outcomes. This study demonstrates that a contextually based and culturally safe age-friendly environments can facilitate engagement and participation by kaumatua for kaumatua. TRIAL REGISTRY: Australia New Zealand Clinical Trial Registry (ACTRN12617001396314); Date Registered: 3 October 2017 (retrospectively registered); https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373733&isClinicalTrial=False.

Engage for Equity: The Role of Trust and Synergy in Community-Based Participatory Research.

Community-based participatory research (CBPR) partnerships exist as complex, dynamic relationships that incorporate shared decision that supports trust development between communities and academics. Within CBPR, the interest in understanding the concept of trust has grown with the realization that, without trust, CBPR relationships fracture. A barrier to monitoring the trust health of a partnership is the lack of a shared operationalization of the concept, its antecedents, and measurement tools. To address these barriers, a six-category trust typology was created as a developmental theory of trust progress. To advance the theory, this article reports on the quantitative structural elements of the trust typology, identifies variability in trust correlates, and creates an empirical foundation for the trust types. Using Engage for Equity data, trust covariates included measures of synergy, CBPR principles, participation, and influence. Structural equation models were used to assess associations between trust types and the latent constructs measured by the items in each measure. The findings demonstrate that the six trust types generally operate on a continuum. Specifically, it does appear that trust deficit, role-based trust, functional trust, proxy trust, and reflective trust are on a single continuum from low to high. Scale scores for reflective trust and proxy trust were consistently and statistically significantly higher than those for functional trust, role-based, neutral, and trust deficit. These results support the construct validity of the trust typology as representing "higher levels" of trust phases. Due to the dynamic nature of partnerships, regular monitoring of partnership trust types can serve as a proxy for partnership functioning.

Engage for Equity: A Long-Term Study of Community-Based Participatory Research and Community-Engaged Research Practices and Outcomes.

Community-based participatory research (CBPR) and community-engaged research have been established in the past 25 years as valued research approaches within health education, public health, and other health and social sciences for their effectiveness in reducing inequities. While early literature focused on partnering principles and processes, within the past decade, individual studies, as well as systematic reviews, have increasingly documented outcomes in community support and empowerment, sustained partnerships, healthier behaviors, policy changes, and health improvements. Despite enhanced focus on research and health outcomes, the science lags behind the practice. CBPR partnering pathways that result in outcomes remain little understood, with few studies documenting best practices. Since 2006, the University of New Mexico Center for Participatory Research with the University of Washington's Indigenous Wellness Research Institute and partners across the country has engaged in targeted investigations to fill this gap in the science. Our inquiry, spanning three stages of National Institutes of Health funding, has sought to identify which partnering practices, under which contexts and conditions, have capacity to contribute to health, research, and community outcomes. This article presents the research design of our current grant, Engage for Equity, including its history, social justice principles, theoretical bases, measures, intervention tools and resources, and preliminary findings about collective empowerment as our middle range theory of change. We end with lessons learned and recommendations for partnerships to engage in collective reflexive practice to strengthen internal power-sharing and capacity to reach health and social equity outcomes.

Space within the Scientific Discourse for the Voice of the Other? Expressions of Community Voice in the Scientific Discourse of Community-Based Participatory Research.

Community-based participatory research (CBPR) has captured public health attention and support because it is positioned as an approach that involves researchers and communities as equitable partners in addressing health disparities. However, it is unknown the extent to which CBPR creates a participatory space in the scientific discourse to signal "community voice," which we define as textual expression of community-centered perspectives on collective roles, interests, and worldviews. In this study, we utilized the culture-centered approach to examine the expression of community voice in the abstracts and public health relevance statements of 253 extramural CBPR projects in the U.S. that received funding from the National Institute of Health and Centers for Disease Control and Prevention in 2009. We found that project abstracts and public health relevance statements contain four textual domains, or potential sites of contest to signal the articulation of community agency and voice within the CBPR projects. These domains include: 1) the rationale for the community health issue, 2) the roles of community partners, 3) community-centered outcomes of the partnership, and 4) elements of participatory research process. The degree of culture-centeredness of the texts is suggested in the extent to which articulations of community agency and voice are signaled across the four domains. We conclude that the dynamics of CBPR may shape culture-centered expressions of problem identification, solution configuration, structural transformations, reflexivity, values, and agency in the project abstracts and public health relevance statements.

Correlates of Health-Related Quality of Life for Maori Elders Involved in a Peer Education Intervention.

The purpose of this study was to identify social determinant and communication correlates of health-related quality of life for kaumatua (Maori elders) in New Zealand. A total of 209 kaumatua completed a self-report survey of self-rated health, physical/mental quality of life, spirituality, and a series of questions about social determinants (e.g., factors related to income) and communication variables (e.g., loneliness, social support, cultural identity, and perceived burden/benefit). The survey was baseline data for a peer education intervention to help kaumatua work through life transitions in older age. The main findings of this study were that social determinants, particularly difficulty paying bills, accounted for a small amount of variance in physical/mental quality of life and self-rated health. Further, the communication correlates of loneliness, perceived burden, and desired support accounted for about three times as much variance in these two outcomes all with negative associations. Strength of tribal identity, importance of whanau (extended family), and knowledge of tikanga (customs and protocols) accounted for a moderate amount variance in spirituality with positive associations. These findings have important theoretical and practical implications for positive aging.

Culture-centeredness in community-based participatory research: contributions to health education intervention research.

Health education research emphasizes the importance of cultural understanding and fit to achieve meaningful psycho-social research outcomes, community responsiveness and external validity to enhance health equity. However, many interventions address cultural fit through cultural competence and sensitivity approaches that are often superficial. The purpose of this study was to better situate culture within health education by operationalizing and testing new measures of the deeply grounded culture-centered approach (CCA) within the context of community-based participatory research (CBPR). A nation-wide mixed method sample of 200 CBPR partnerships included a survey questionnaire and in-depth case studies. The questionnaire enabled the development of a CCA scale using concepts of community voice/agency, reflexivity and structural transformation. Higher-order confirmatory factor analysis demonstrated factorial validity of the scale. Correlations supported convergent validity with positive associations between the CCA and partnership processes and capacity and health outcomes. Qualitative data from two CBPR case studies provided complementary socio-cultural historic background and cultural knowledge, grounding health education interventions and research design in specific contexts and communities. The CCA scale and case study analysis demonstrate key tools that community-academic research partnerships can use to assess deeper levels of culture centeredness for health education research.

Early Impact of the Patient Protection and Affordable Care Act on People Living With HIV: A Systematic Review.

The US Patient Protection and Affordable Care Act (ACA) was the most influential policy-related change to the care of people living with HIV in decades. We systematically searched and analyzed peer-reviewed, empirical research reporting on ACA-related aspects of HIV care post-ACA full implementation, finding 12 articles that met search criteria. The results revealed largely positive evidence regarding the ACA impact on people living with HIV, particularly on their health care coverage in Medicaid expansion states. More recent reporting included improvement in virologic suppression. However, early evidence has been somewhat fragmented, and important questions concerning the impact of the ACA on HIV care quality, patients, and providers remain unanswered. As the political struggle over the ACA continues, future analyses should use national- and state-level data to examine ACA impact on HIV care quality and patient-centered health outcomes to provide in-depth, holistic understanding of HIV care in the wake of this policy change.

Efficacy of an incentive intervention on secondary prophylaxis for young people with rheumatic fever: a multiple baseline study.

BACKGROUND: Acute rheumatic fever in New Zealand persists and is a barometer of equity as its burden almost exclusively falls on Maori and Pacific Island populations. The primary objective of this study is to determine whether an incentive programme will result in increased secondary prophylaxis injections over a one-year period compared to a baseline period prior to the intervention. METHODS: The evaluation used a multiple baseline study to determine whether an incentive consisting of a mobile phone and monthly "top-up" (for data/calls) resulted in increased injections, increased texts/calls with nurses, reduced number of visits to get a successful injection, less medicine wasted, and increased nurse satisfaction. Participants were 77 young people (aged 14-21) on an acute rheumatic fever registry in Waikato region, New Zealand classified as either fully adherent (all injections received and no more than one late) or partially adherent based on injections at baseline. RESULTS: There was a sharp increase in injections for intermittent patients post-intervention and then a slight decrease overtime, while fully adherent patients maintained their high rate of injections (p = .003). A similar pattern for nurse satisfaction emerged (p = .001). The number of calls/texts increased for all patients (p = .003). The number of visits went down for partially adherent patients and up for fully adherent patients (p = .012). The overall incremental cost-effectiveness was $989 per extra successful injection although costs increased sharply toward the end of the intervention. CONCLUSIONS: Incentivising secondary prophylaxis appears to have a strong impact for partially adherent patients, particularly during the early periods following the initiation of the intervention. Enhancing communication with patients who returned to care may result in more sustainable adherence. TRIAL REGISTRATION: Retrospectively registered: Australia New Zealand Clinical Trials Registry ACTRN12618001150235 , 12 July 2018.