Factors driving norovirus transmission in long-term care facilities: A case-level analysis of 107 outbreaks.

Norovirus is the most common cause of gastroenteritis outbreaks in long-term care facilities (LTCFs) in the United States, causing a high burden of disease in both residents and staff. Understanding how case symptoms and characteristics contribute to norovirus transmission can lead to more informed outbreak control measures in LTCFs. We examined line lists for 107 norovirus outbreaks that took place in LTCFs in five U.S. states from 2015 to 2019. We estimated the individual effective reproduction number, Ri, to quantify individual case infectiousness and examined the contribution of vomiting, diarrhea, and being a resident (vs. staff) to case infectiousness. The associations between case characteristics and Ri were estimated using a multivariable, log-linear mixed model with inverse variance weighting. We found that cases with vomiting infected 1.28 (95 % CI: 1.11, 1.48) times the number of secondary cases compared to cases without vomiting, and LTCF residents infected 1.31 (95 % CI: 1.15, 1.50) times the number of secondary cases compared to staff. There was no difference in infectiousness between cases with and without diarrhea (1.07; 95 % CI: 0.90, 1.29). This suggests that vomiting, particularly by LTCF residents, was a primary driver of norovirus transmission. These results support control measures that limit exposure to vomitus during norovirus outbreaks in LTCFs.

Sexual and Reproductive Health Advocacy Successes, Failures, and Needs in the United States: Perspectives From Key Stakeholders.

Physician advocates for sexual and reproductive health (SRH) care have been active in the United States for decades. Despite such activism, access to SRH services has been fraught with persistent restrictions, particularly for abortion care. We sought the perspectives of key stakeholders on what makes for an effective SRH physician advocate and thoughts about the successes, failures, and needs of the abortion advocacy movement. We interviewed 15 SRH key informants (KIs) in sectors with expertise in organizational policy and advocacy (n = 6); clinical leadership and education (n = 3), media (n = 3), and reproductive justice (n = 3). The analytic team coded repeating ideas and conducted a thematic analysis, organizing findings within KI perspectives on the role of physician advocates in the field of abortion and contraception; successes, failures, and needs in abortion and contraception advocacy; and recommendations on the composition and components of an ideal clinician advocacy training program. KIs relayed that skill building related to communication, developing relationships with changemakers, and understanding political systems was critical for effective advocacy. They felt clinician advocacy training programs should include providers other than physicians and be designed for trainees to build relationships with one another over time. KI perspectives can be valuable in informing advocacy training programs and for contributing strategic approaches to increasing equitable and widespread access to SRH services.

Stakeholder perspectives in New York State on reproductive health and pregnancy intention screening in primary care: A qualitative study.

OBJECTIVE: To assess New York State stakeholders' perspectives regarding providing reproductive health services in primary care settings, including asking patients about pregnancy intentions and providing long-acting reversible contraception (LARC). STUDY DESIGN: We conducted semistructured key-informant interviews (n = 22) with stakeholders representing diverse sectors, including primary care (family medicine) and specialty (obstetrician/gynecologist) physicians, health educators/promoters, advocates, and public health/health care professionals. Grounded theory methodology informed sampling and thematic analysis within and across sectors. RESULTS: Key informants across sectors supported integrating reproductive health services into primary care. Pregnancy intention screening was considered appropriate yet required improved measures. Such screening was viewed as fostering childbearing discussions and counseling for contraception/preconception health that could benefit patients while also requiring attention to concerns from the patient (e.g., potential for coercion, access barriers) and health care systems (e.g., buy-in, training) contexts. Three themes related to LARC included provider bias, knowledge and training, counseling and patient education, and logistics/financial situation, which were differentially emphasized by stakeholder sector; providers expressed greater concern regarding training, bias, and logistical considerations, whereas health educators and advocates focused on patient education and autonomous decision-making. Similarly, awareness of reproductive justice principles varied by sector. CONCLUSION: There is consensus among informants from the 5 sectors for expanding reproductive health services in primary care. This will require reproductive health-related training for providers, organizational buy-in, and system protocol changes, including unbiased contraceptive counseling of all methods, specifically balancing discussion of LARC effectiveness with information regarding side effects. Incorporating reproductive justice principles may increase informed patient decision-making and reproductive autonomy. IMPLICATIONS: Expanding reproductive health services in primary care requires provider training and protocols for patient-centered care, including unbiased provision of all contraceptive options. The reproductive justice framework offers the possibility of addressing diverse stakeholders' concerns for both preconception and contraceptive care with patient decision-making at the forefront.

Understanding community family medicine preceptors' involvement in educational scholarship: perceptions, influencing factors and promising areas for action.

BACKGROUND: Residency training is increasingly occurring in community settings. The opportunity for community-based scholarship is untapped and substantial. We explored Community Family Medicine Preceptors' understanding of Educational Scholarship (ES), looked at barriers and enablers to ES, and identified opportunities to promote the growth of ES in this setting. METHODS: We conducted semi-structured interviews with fifteen purposively chosen community-based Family Medicine preceptors in a distributed Canadian family medicine program. RESULTS: Community Family Medicine Preceptors strongly self-identify as clinical teachers. They are not well acquainted with the definition of ES, but recognize themselves as scholars. Community Family Medicine Preceptors recognize ES has significant value to themselves, their patients, communities, and learners. Most Community Family Medicine Preceptors were interested and willing to invest in ES, but lack of time and scarcity of primary care research experience were seen as barriers. Research process support and a connection to the academic center were considered enablers. Opportunities to promote the growth of ES include recognition that there are fundamental differences between community and academic sites, the development of a mentorship program, and a process to encourage engagement. CONCLUSIONS: Community Family Medicine Preceptors identify foremost as clinician teachers. They are engaged in and recognize the value of ES to their professional community at large and to their patients and learners. There is a growing commitment to the development of ES in the community.

CONTEXTE: Les stages de résidence se font de plus en plus en milieu communautaire, un milieu qui offre des possibilités de scholarship intéressantes demeurant inexploitées. Nous avons étudié la compréhension qu'ont les superviseurs en médecine familiale communautaire au sujet du scholarship de l'éducation (SÉ), examiné les obstacles et les facteurs favorables au SÉ et identifié les possibilités de le promouvoir dans le cadre communautaire. MÉTHODES: Nous avons mené des entretiens semi-structurés avec quinze cliniciens enseignants en médecine familiale communautaire choisis à dessein dans un programme de médecine familiale décentralisée au Canada. RÉSULTATS: Les superviseurs en médecine familiale communautaire se définissent fermement comme cliniciens enseigants. Peu familiers avec la définition du SÉ, ils se considèrent néanmoins comme érudits. Ils reconnaissent l'importance considérable du scholarship de l'éducation autant pour eux que pour leurs patients, les communautés et les apprenants. La plupart des superviseurs en médecine familiale communautaire se disent intéressés et disposés à s'investir en SÉ, mais se sentent limités par le manque de temps et le peu d'expérience en recherche en soins primaires. Le soutien au processus de recherche et un lien avec le centre universitaire sont considérés comme éléments favorables. La possibilité de développer le SÉ passe par la reconnaissance des différences fondamentales entre les sites communautaires et universitaires, la création d'un programme de mentorat et la mise en place d'un processus visant à encourager l'engagement. CONCLUSIONS: Les superviseurs en médecine familiale communautaire se définissent avant tout comme des cliniciens enseignants. Ils s'investissent dans le SÉ et ils reconnaissent son importance pour leur communauté professionnelle, leurs patients et leurs apprenants. Il y a un engagement croissant envers le développement du SÉ dans la communauté.

The association of pregnancy control, emotions, and beliefs with pregnancy desires: A new perspective on pregnancy intentions.

CONTEXT: Standard pregnancy intentions measures do not always align with how people approach pregnancy. Studies that have investigated beyond a binary framework found that those with "ambivalent" feelings towards pregnancy are less likely to use contraception consistently, but the reasons for this are unclear. We sought to gain a nuanced understanding of pregnancy desires, and how perceptions about pregnancy are associated with contraceptive use. METHODS: We used non-probability quota sampling based on sex, age, and geographic region for a web-based survey of heterosexual men and women, aged 21-44 years, who could become pregnant/impregnate and were not currently pregnant (n = 1,477; 51% female). The survey was created using unique items informed by recent literature. Bivariate and multivariable analyses explored relationships between various perceptions about pregnancy with pregnancy desires categorized as: wanting a pregnancy, not wanting a pregnancy, and not trying but would be okay with a pregnancy. We conducted a sub-group analysis of those who were not trying but would be okay with a pregnancy (n = 460), using descriptive statistics to examine how consistent contraceptive use was associated with emotions and beliefs about avoiding pregnancy. RESULTS: After adjustment, those who felt that pregnancy may not always be avoidable, but instead determined by fate/higher power, or a natural process that happens when it is meant to, were significantly more likely (aOR: 1.83, 95% CI: 1.05-3.36; aOR: 2.21, 95% CI: 1.29-3.76, respectively) to report not trying but being okay with pregnancy, whereas those with negative feelings about a pregnancy were less likely to feel okay about a pregnancy (aOR: 0.11, 95% CI: 0.08-0.15), versus not wanting a pregnancy. In the sub-group analysis, those who felt pregnancy was determined by fate/higher power or a natural process were more likely to report not using contraception consistently (70%, 68%, respectively). CONCLUSIONS: Those who state they are not trying but would be okay with pregnancy may not use contraception consistently because of beliefs that pregnancy is predetermined. Our findings support less categorical and more multidimensional approaches to measuring fertility intentions, with important implications for reproductive health service provision.

Effectively engaging physicians in system change.

What started as a prospective study to support clinical leaders and inform strategies to engage their peers in system change was impacted due to a rapidly evolving political agenda amid a pandemic, affecting both organizations and outcomes. Participants in this mixed methods study in one Local Health Integrated Network (LHIN) in Ontario included clinical leaders and community physicians over a period of 14 months. As the provincial government shifted regional healthcare governance from LHINs to Ontario Health Teams, there was an increase in the engagement of community physicians and leaders identified a noticeable culture shift with the potential to drive change. High-performing healthcare systems are dependent not only on physicians who can lead and engage others but a government that can acknowledge this.

Women's Perspectives on Reproductive Health Services in Primary Care.

BACKGROUND AND OBJECTIVES: Primary care providers (PCPs) are increasingly offering reproductive health (RH) services to help address patients' unmet contraceptive needs and improve pregnancy outcomes. We sought to understand patient perspectives on receipt of RH services in primary care settings. METHODS: We used a purposeful stratified sampling approach to recruit women aged 21 to 40 years into focus groups (FGs) and in-depth interviews (IDIs). We held all four FGs in two New York City neighborhoods and all 18 IDIs in two upstate NY suburban/rural neighborhoods (each with half of the neighborhoods above and below the median county income in each setting type). We explored participants' preferences for RH services from PCPs, including their feelings about being asked about pregnancy intentions. We also asked their opinions on three distinct pregnancy intention screening and reproductive health needs assessment questions. Data analysis involved an iterative process of excerpt coding and interpretive analysis to identify key themes. RESULTS: We conducted four FGs and 18 IDIs with a total of 39 women. Participants were receptive to the availability of RH services in primary care and the benefits to streamlining this care, provided clinicians approach these services in a manner that respects patient autonomy and reproductive desires. They discussed a lack of preconception care counseling and concerns about primary care providers' training and/or comfort with RH, as well as time spent with patients. Participants had the most positive response to the proposed question "Can I help you with any reproductive health services today, such as birth control or planning for a healthy pregnancy?" based on its open-endedness, inclusiveness, and promotion of reproductive autonomy. CONCLUSIONS: The findings of this study support the continued expansion of RH services in primary care settings. Future research should test the preferred RH service needs question to understand how it may affect service delivery, patient satisfaction, reproductive autonomy, as well as unmet contraceptive need and indicators of maternal and child health.

Primary care patients' preferences for reproductive health service needs assessment and service availability in New York Federally Qualified Health Centers.

OBJECTIVES: Expanding reproductive health services in primary care could increase access to preconception and contraceptive services. We assessed patients' preferences around wording, frequency and staffing for reproductive health service needs assessment and availability of a range of reproductive health services in primary care. STUDY DESIGN: We implemented a cross-sectional anonymous survey of adults in the waiting rooms of four Federally Qualified Health Centers (FQHCs) in New York State in 2017. We present descriptive findings on preferences, including preferences among four questions on reproductive health needs assessment, and differences by socio-demographic characteristics. RESULTS: We had an 89.4% response rate. Of 1,071 respondents, 68.8% self-reported gender as female, 26.5% male and 4.1% transgender/other, while 40.8% self-identified as black non-Hispanic, 32.2% white non-Hispanic, 17.6% Hispanic and 9.4% other. A third had no preferred reproductive health needs assessment question (34.5%), while another third preferred, "Can I help you with any reproductive health services today such as birth control or planning a healthy pregnancy?" (31.5%). Respondents wanted to be asked by a doctor (43.9%) or nurse/medical assistant (21.1%). Females wanted to be asked at every visit (52.9%) more than males (43.9%) and transgender/other individuals (34.1%, p < 0.01). The majority would like to be able to access contraception (59.0%) and sexually transmitted infection (STI) testing (55.4%) at their FQHC. CONCLUSIONS: Most patients supported inclusion of reproductive health discussions and contraception and STI services at these FQHCs. Among those with a preference, patients preferred to be asked about reproductive health service needs rather than pregnancy intentions or desires. IMPLICATIONS: Primary care settings should consider routine inclusion of reproductive health needs assessments over screening for pregnancy intentions or desires. Primary care settings which do not currently provide contraception and sexually transmitted infection testing should consider making these services available.

Physician perspectives on routine pregnancy intention screening and counseling in primary care.

OBJECTIVES: To assess factors associated with routine pregnancy intention screening by primary care physicians and their support for such an initiative. STUDY DESIGN: We conducted a cross-sectional survey study of 443 primary care physicians in New York State. We performed multivariable logistic regression analyses of physician support for routine pregnancy intention screening and implementation of screening in the last year. Predictors included in the models were physician age, sex, specialty, clinic setting, and, for the outcome of support for screening, experience with screening in the last year. RESULTS: In this convenience sample, the vast majority of respondents from all specialties (88%) felt pregnancy intention screening should be routinely included in primary care, with 48% reporting that they routinely perform such screening. The preferred wording for this question was one which assessed reproductive health service needs. In multivariable analyses, internal medicine physicians were less likely than family medicine physicians to have provided routine pregnancy intention screening (aOR = 0.15, 95% CI 0.09, 0.25). Only 8% of the sample reported they required more training to implement pregnancy intention screening, but more reported needing training prior to contraceptive provision (17%), contraceptive counseling (16%), and preconception care (15%). More internal medicine and other types of doctors cited a need for this additional training than family medicine physicians. CONCLUSIONS: Most responding primary care physicians supported routine integration of pregnancy intention screening. Incorporating additional training, especially for internal medicine physicians, in contraception and preconception care counseling is key to ensuring success. IMPLICATIONS STATEMENT: Responding primary care physicians supported routine inclusion of reproductive health needs assessment in primary care. Primary care may become increasingly important for ensuring access to a full range of reproductive health services. Providing necessary training, especially for internal medicine physicians, is needed prior to routine inclusion.

National approaches to promote sports and physical activity in adults with disabilities: examples from the Netherlands and Canada.

PURPOSE: This study described how the Dutch and Canadian governments promote high performance sports, recreational sports, and physical activity (PA) among adults with disabilities on a national level. METHODS: An internet-based study was conducted to identify and select relevant documents and websites containing information about the national approach to promote disability sports and physical activities in the Netherlands and Canada. RESULTS: Both governments promote high performance sports in similar ways, but use different strategies to promote recreational sports and physical activities. The Dutch approach is characterized by using time-limited programs focusing on enhancement of sports infrastructure and inter-sector collaboration in which municipalities have key roles. The Canadian government promotes recreational sports in disabled populations by supporting programs via bilateral agreements with provinces and territories. Furthermore, the level of integration of disability sports into mainstream sports differs between countries. CONCLUSIONS: The findings of this study may inspire policy makers from different countries to learn from one another's policies in order to optimize national approaches to promote disability sports and PA on all levels. Implications for rehabilitation It is recommended for policy makers of national governments to develop and implement policy programs that promote sports and physical activities among people with disabilities because of its potential impact on functioning, participation, quality of life, and health. Insight into national approaches to promote sport and physical activities is relevant for rehabilitation practice to understand ongoing opportunities for people with disabilities to stay physically active after rehabilitation through participation in home and/or community-based sport and physical activities. It seems worthwhile to integrate activities to promote sport and physical activities in rehabilitation in such a way that it fits with the current governmental approach. It is recommended to set up international collaborations to develop and share knowledge about effective and sustainable national approaches to promote sports and physical activities among people with disabilities.

The Intersectionality of Racial and Gender Discrimination among Teens Exposed to Dating Violence.

Objective: Driven by intersectionality, a central tenet of Critical Race Theory, this study examines the combined associations of racial and gender discrimination, which are interlocking, macro-level social forces, and teen dating violence (TDV). Design: Self-report surveys were administered via Audio Computer Assisted Self Interview (ACASI) equipment. Logistic regression models were used to estimate associations between racial and gender discrimination and TDV. Setting: Study participants were recruited during August 2003 to June 2004 from high school health classes and an after-school program located in South Bronx neighborhoods of New York City. Participants: Non-probability sample of 142 Black and Latino teens aged 13-19 years who reported experiences dating someone of a different sex. Main Measures: Experienced discrimination based on race and gender adapted from the Experiences of Discrimination (EOD) instrument, dating violence items from the Youth Dating Violence Survey. Results: Of the participants, 40.1% reported experiencing both racial and gender discrimination, and nearly all (93%) experienced dating violence. Participants reporting both racial and gender discrimination were 2.5 times more likely to report experiencing the highest frequency of dating violence, adjusted for age and sex (95% CI: 1.0-6.7). A dose-response of EOD observed in unadjusted models (P for trend =.024) was no longer statistically significant after adjustment for age and sex (P for trend =.073). Conclusions: Strategies to prevent TDV in this population should not ignore the compounding negative effects of racial and gender discrimination.

Development of a wellness trust to improve population health: Case-study of a United States urban center.

Across the United States health systems are recognizing the urgency of addressing the social determinants of health in order to improve population health. Wellness trusts, modeled after financial trusts support primary health prevention in community settings, provide an innovative opportunity for better community-clinical linkages, collaboration, and impact. This study aimed to understand the necessary tenets for a wellness trust in Brooklyn, New York (USA) and examined community interest and political will; administrative, financing, and leadership structures; and metrics and data sources to monitor and assess impact. We employed a multi-method design. Key informant interviews (KIIs) (n = 15) were conducted from 7/2016 to 1/2017. A content analysis of grey literature was used to analyze community interest and political will (n = 38). Extant datasets, such as New York City Community District profiles, were reviewed, and a narrative review was used to assess cost-effectiveness of prevention interventions (n = 33). The KIIs and grey literature underwent thematic analysis. Findings indicated healthcare issues dominated the health agenda despite recognition of social determinants of health. Braided funding (discrete funds that are coordinated but tracked separately) and blended funding (funds pooled from multiple sources tracked together) are common funding mechanisms. Robust data systems exist to assess impact. Indicators should address social determinants, performance and impact, be measurable, geographically specific, and include communities. Wellness trusts should be sustainable, engage communities, foster collaboration, and have adequate capacity. The Collective Impact Framework, a mechanism to coordinate and maximize efforts, offers this organizational structure. Wellness trusts are promising mechanisms to advance population health.

National evaluation of policies governing funding for wheelchairs and scooters in Canada: Évaluation nationale des politiques régissant le financement des fauteuils roulants, des triporteurs et des quadriporteurs au Canada.

BACKGROUND: Wheelchairs, scooters, and related equipment are essential for the well-being of individuals with limited mobility and impact participation, health, and quality of life. PURPOSE: Our objective was to identify and evaluate policies governing equipment funding for Canadian adults. We reviewed funding legislation and program documentation for adult Canadians (≥18 years of age) covered by their provincial, territorial, or federal health care plan. Documents were obtained online or through administrative staff. Policy evaluation was guided by the Disability Policy Lens from the Canadian Disability Policy Alliance. KEY ISSUES: Coverage ranges from full funding for all individuals within the jurisdiction to programs limited by strict eligibility criteria. Each jurisdiction defines "disability" or "basic/essential need" differently, contributing to further funding disparities. IMPLICATIONS: Funding policies differ substantially across Canada, resulting in unequal access to equipment dependent on province or territory. We identified eligibility, funding, definitions of mobility, repair and replacement, and prescriber requirement benchmarks that represent policy targets for improved access.

Achievement of personalized pain goal in cancer patients referred to a supportive care clinic at a comprehensive cancer center.

BACKGROUND: Cancer pain initiatives recommend using the personalized pain goal to tailor pain management. This study was conducted to examine the feasibility and stability of personalized pain goal, and how it compares to the clinical pain response criteria. METHODS: Records of 465 consecutive cancer patients seen in consultation at the Supportive Care Clinic were reviewed. Pain relief was assessed as clinical response (≥30% or ≥2 point pain reduction) and personalized pain goal response (pain ≤ personalized pain goal). RESULTS: One hundred fifty-two (34%), 95 (21%), and 163 (37%) patients presented with mild (1-4), moderate (5-6), and severe (7-10) pain, respectively. Median age (59 years), males (52%), and advanced cancer status (84%) did not differ by pain category. Median personalized pain goal at initial clinic consult was 3 (interquartile range, 2-3), was similar across pain groups, and remained unchanged (P = .57) at follow-up (median, 14 days). Clinical response was higher among patients with severe pain (60%) as compared with moderate (40%) and mild pain (33%, P < .001). Personalized pain goal response was higher among patients with mild pain (63%) as compared with moderate (44%) and severe pain (27%, P < .001). By using personalized pain goal response as the gold standard for pain relief, the sensitivity of clinical response was highest (98%) among patients with severe pain, but it had low specificity (54%). In patients with mild pain, clinical response was most specific for pain relief (98%), but had low sensitivity (52%). CONCLUSIONS: Personalized pain goal is a simple patient-reported outcome for pain goals. The majority of patients were capable of stating their desired level for pain relief. The median personalized pain goal was 3, and it was highly stable at follow-up assessment.

Neighborhood-specific epigenome analysis: the pathway forward to understanding gene-environment interactions.

Morbidity and mortality associated with complex diseases are expected to increase as the population ages and the number of Americans living in poverty continues to expand. Therefore, improved translation of research findings into clinical practice and public health policy must become a priority. This commentary emphasizes the need for a new research model that accommodates the complex nature of disease etiology.

Performance feedback: an exploratory study to examine the acceptability and impact for interdisciplinary primary care teams.

BACKGROUND: This mixed methods study was designed to explore the acceptability and impact of feedback of team performance data to primary care interdisciplinary teams. METHODS: Seven interdisciplinary teams were offered a one-hour, facilitated performance feedback session presenting data from a comprehensive, previously-conducted evaluation, selecting highlights such as performance on chronic disease management, access, patient satisfaction and team function. RESULTS: Several recurrent themes emerged from participants' surveys and two rounds of interviews within three months of the feedback session. Team performance measurement and feedback was welcomed across teams and disciplines. This feedback could build the team, the culture, and the capacity for quality improvement. However, existing performance indicators do not equally reflect the role of different disciplines within an interdisciplinary team. Finally, the effect of team performance feedback on intentions to improve performance was hindered by a poor understanding of how the team could use the data. CONCLUSIONS: The findings further our understanding of how performance feedback may engage interdisciplinary team members in improving the quality of primary care and the unique challenges specific to these settings. There is a need to develop a shared sense of responsibility and agenda for quality improvement. Therefore, more efforts to develop flexible and interactive performance-reporting structures (that better reflect contributions from all team members) in which teams could specify the information and audience may assist in promoting quality improvement.