Interprofessional education in the clinical learning environment: a mixed-methods evaluation of a longitudinal experience in the primary care setting.

Team collaboration in our healthcare workforce is necessary to effectively address multifaceted medical and social needs, especially for those impacted by systemic inequities. Effective interprofessional practice and education models including curricula are needed to prepare a practice ready healthcare workforce for team collaboration. Most healthcare trainee interprofessional experiences take place episodically in classroom settings. However, creating a culture that supports team-based learning and interprofessional clinical practice requires teaching skills (e.g., communication, collaboration, shared decision-making, coordination of care) longitudinally in the clinical setting. A weekly interprofessional clinic for patients/clients with chronic health conditions was organized in three primary care practices. Trainees from nutrition, social work, medicine, and physician assistant programs worked with supervising clinicians from each field. Surveys, interviews, and focus groups assessed the effects of interprofessional education and training in the primary care setting. Results show the longitudinal experiential IPE program significantly improved knowledge, attitudes, skills, and values addressing key interprofessional competencies. Qualitative results complement survey data and highlight key themes addressing patient-centered care and team dynamics. These findings demonstrate the importance of longitudinal, immersive team-based interprofessional training in the clinical learning environment.

Racism and the Reproductive Health Experiences of U.S.-Born Black Women.

OBJECTIVE: To explore Black women's lived experiences of racism and the associated effects on reproductive health decisions and the reproductive health care experience. METHODS: We recruited participants through social media and community outreach. We conducted semi-structured individual interviews focusing on Black women's lived experiences of racism and their effects on reproductive health. We coded and analyzed interview transcripts using process coding methodology. RESULTS: Participants (N=21) were 21-45 years old and from Boston, Chicago, and Atlanta. Our primary themes were: 1) reproductive health racism across the life course, 2) anti-Black racism in the reproductive health care system, and 3) self-protective actions when interacting with the reproductive health care system. Reproductive racism across the life course included subthemes of early sexualization of Black women, heightened awareness of reproductive health inequities, and knowledge of reproductive oppression. Anti-Black racism in the reproductive health care system included subthemes of absence of shared decision making; vicarious reproductive health experiences; stereotyping, invalidation, and dismissal by reproductive health professionals; and medical mistrust. Participants guarded themselves against racism within reproductive health care by engaging in a variety of self-protective actions including seeking a health care professional of color, overpreparing for their appointments, enlisting advocates, seeking care only when desperate, and heightening symptoms to be heard. CONCLUSION: Personal, vicarious, and historical experiences of racism within reproductive health care triggered participants to perform self-protective actions when interacting with the reproductive health care system. These actions served to promote safety, autonomy and rehumanization within a system that has historically and contemporarily devalued Black reproductive health.

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

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

Exploring the physician's role in contraceptive counseling at the time of abortion in the US.

OBJECTIVE: We explored how physicians conceptualize their role in contraceptive counseling at the time of abortion, including identifying clinician attitudes that may lead to patients' perceptions of contraceptive coercion. STUDY DESIGN: We conducted individual semi-structured interviews using questions based on components of the Theory of Planned Behavior. We recruited physician abortion providers using purposeful sampling to attain diversity in practice setting and geographic practice region. We analyzed transcribed interviews using initial and values coding methods. RESULTS: We interviewed 39 participants across the United States, who primarily self-reported as White female obstetrician gynecologists (OB/GYNs) aged 25 to 44. Over half of participants practiced in an academic setting. Participants perceived providing patient education and taking a patient-centered approach as part of their role in contraceptive counseling. Participants also believed it was their responsibility to prevent unintended pregnancies and subsequent abortions among their patients. External motivations behind this belief included wanting patients to avoid the challenges of obtaining another abortion, particularly in states with multiple abortion restrictions. Internal motivations included valuing professional goal attainment, discomfort with abortion, and abortion stigma. When physicians counseled about contraception, many expressed preferences toward methods of long-acting reversible contraception (LARC) and an emphasis on contraception provision for adolescents and women with prior abortions. CONCLUSIONS: Physicians providing abortions strive to use a patient-centered approach to contraceptive counseling. However, many continue to be motivated by the goal of avoiding a subsequent abortion which patients may perceive as coercion towards contraceptive uptake. IMPLICATIONS: Considering contraceptive counseling as a means to prevent subsequent abortion may lead to coercive practices, especially with specific patient populations. Moral codes and abortion stigma influence physicians' counseling practices and physicians must examine their personal values and motivations behind recommending contraception after an abortion.

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

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

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

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

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

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

Understanding Barriers to Contraception Screening and Referral in Female Adolescents and Young Adults with Cancer.

Background: Contraception screening and referral occur infrequently in cancer care for young women of reproductive age. Barriers to contraception screening and referral in this setting have not been thoroughly identified. Objectives: We sought to understand oncology clinicians' current practices and perceptions of barriers to screening and referring young women for adequate contraception during cancer treatment. Methods: We conducted individual semi-structured interviews with 19 oncology clinicians whom we recruited from an urban, northeast medical center. Participants included physicians, advanced practice clinicians, and nurses in surgical and medical oncology. The interview guide addressed core components of the Promoting Action on Research Implementation in Health Services framework, and subsequent directed content analysis identified themes indicative of barriers to contraception screening and referral. Findings: Participants varied significantly in their current contraception screening practices; many conflated early pregnancy diagnosis or pregnancy avoidance counseling with contraception, whereas others described inaccurate contraceptive recommendations for specific clinical scenarios. Participants also lacked clarity of roles and responsibilities within the oncologic care team for contraception and assumed that another team member had addressed contraception. Participants perceived themselves to lack adequate education about contraception, which precluded contraception discussions. Conclusion: We recommend cancer centers consider these possible barriers to contraception screening and referral by promoting development of institutional guidelines to standardize contraception screening and referral, clarifying roles and responsibilities for contraception discussions within the care team, and expanding oncology clinician education on contraception. National professional organizations should work to expand guidelines to inform and support this process in clinical practice.

Health Disparities in Access to Nonpharmacologic Therapies in an Urban Community.

OBJECTIVE: The overuse of prescription opioids for chronic pain is recognized as a public health crisis. Yet, poor access to nonpharmacologic treatments is the norm in low-income, racially and ethnically diverse patients with chronic pain. The main objective of this study was to understand how chronic pain impacts low-income individuals with chronic pain and their communities from multiple perspectives. DESIGN: This was a qualitative study using a Science Café methodology. SETTING: The Science Café event was held at an urban community center in Boston, MA. SUBJECTS: Inclusion criteria included the following: having the ability to attend the event, being at least 18 years of age or older, and participating in English. METHODS: Data were collected through self-reported questionnaires and audio or video recordings of two focus groups. Quantitative and qualitative data were analyzed with SAS 9.3 and NVivo 10. RESULTS: Thirty participants attended the Science Café event. The average age was 45 years, 77% reported as female, 42% identified as black, and 19% as Hispanic. Participants identified themselves as either patients (46%) or providers (54%) to the chronic pain community. Our forum revealed three major themes: (1) nonpharmacologic options for chronic pain management are warranted, (2) larger sociodemographic and contextual factors influence management of chronic pain, and (3) both patients and providers value the patient-provider relationship and acknowledge the need for better communication for patients with chronic pain. CONCLUSIONS: Future research should consider identifying and addressing disparities in access to nonpharmacologic treatments for chronic pain in relation to underlying social determinants of health, particularly for racially and ethnically diverse patients.

Forging Alliances in Interdisciplinary Rehabilitation Research (FAIRR): A Logic Model.

In a patient-centered care era, rehabilitation can benefit from researcher-clinician collaboration to effectively and efficiently produce the interdisciplinary science that is needed to improve patient-centered outcomes. The authors propose the use of the Forging Alliances in Interdisciplinary Rehabilitation Research (FAIRR) logic model to provide guidance to rehabilitation scientists and clinicians who are committed to growing their involvement in interdisciplinary rehabilitation research. We describe the importance and key characteristics of the FAIRR model for conducting interdisciplinary rehabilitation research.

Engaging women with an embodied conversational agent to deliver mindfulness and lifestyle recommendations: A feasibility randomized control trial.

OBJECTIVE: This randomized controlled trial evaluates the feasibility of using an Embodied Conversational Agent (ECA) to teach lifestyle modifications to urban women. METHODS: Women were randomized to either 1) an ECA (content included: mindfulness, stress management, physical activity, and healthy eating) or 2) patient education sheets mirroring same content plus a meditation CD/MP3 once a day for one month. General outcome measures included: number of stress management techniques used, physical activity levels, and eating patterns. RESULTS: Sixty-one women ages 18 to 50 were enrolled. On average, 51% identified as white, 26% as black, 23% as other races; and 20% as Hispanic. The major stress management techniques reported at baseline were: exercise (69%), listening to music (70%), and social support (66%). After one month, women randomized to the ECA significantly decreased alcohol consumption to reduce stress (p=0.03) and increased daily fruit consumption by an average of 2 servings compared to the control (p=0.04). CONCLUSION: It is feasible to use an ECA to promote health behaviors on stress management and healthy eating among diverse urban women. PRACTICE IMPLICATIONS: Compared to patient information sheets, ECAs provide promise as a way to teach healthy lifestyle behaviors to diverse urban women.

Reducing Preconception Risks Among African American Women with Conversational Agent Technology.

BACKGROUND: Systems and tools are needed to identify and mitigate preconception health (PCH) risks, particularly for African American (AA) women, given persistent health disparities. We developed and tested "Gabby," an online preconception conversational agent system. METHODS: One hundred nongravid AA women 18-34 years of age were screened for over 100 PCH risks and randomized to the Gabby or control group. The Gabby group interacted with the system for up to six months; the control group received a letter indicating their health risks with a recommendation to talk with their clinician. The numbers, proportions, and types of risks were compared between groups. RESULTS: There were 23.7 (SD 5.9) risks identified per participant. Eighty-five percent (77 of 91) provided 6 month follow up data. The Gabby group had greater reductions in the number (8.3 vs. 5.5 risks, P < .05) and the proportion (27.8% vs 20.5%, P < 0.01) of risks compared to controls. The Gabby group averaged 63.7 minutes of interaction time. Seventy-eight percent reported that it "was easy to talk to Gabby" and 64% used information from Gabby to improve their health. CONCLUSION: Gabby was significantly associated with preconception risk reduction. More research is needed to determine if Gabby can benefit higher risk populations and if risk reduction is clinically significant.

Reaching women through health information technology: the Gabby preconception care system.

PURPOSE: The Centers for Disease Control and Prevention have endorsed the concept of preconception care (PCC). New tools must be developed to promote PCC. DESIGN: Development and testing of a health information technology system to provide PCC. SETTING: An urban safety net hospital and an urban university. SUBJECTS: Community recruitment of 31 women in focus groups and 15 women participating in observed usability testing; 9 students recruited from the Office of Minority Health Preconception Peer Educators program participated in pilot testing for 2 months. INTERVENTION: Online interactive animated character ("Gabby") designed to identify and modify preconception risks. MEASURES: Qualitative transcripts, preconception risk assessment, server data for system usage, self-administered satisfaction surveys, and follow-up phone calls. ANALYSIS: Descriptive statistics of subjects' demographics, satisfaction, PCC risks, and system usage. Transcripts coded using NVIVO. RESULTS: Subjects (n = 24) reported an average of 23 preconception risks; in the pilot, 83% of risks added to the "My Health To-Do List" were addressed by the subject. Seventy-three percent of risks identified as contemplative progressed to action or maintenance. Differences were noted in effectiveness of the system based on initial stage of change for each risk. CONCLUSION: Results suggest that the PCC system could be effective in influencing positive behavior change. Adding stage of change-focused functionality might have added benefits. This system has great potential to assist in the delivery of PCC.

Ecological barriers and social forces in childhood asthma management: examining routines of African American families living in the inner city.

OBJECTIVE: Asthma affects African American children at unprecedented rates. Researchers have examined the context in which African American families live and experience illness, and suggest that ecological barriers contribute to poor health. In this paper, the authors examine the social forces underlying these ecological barriers and what African American parents living in the inner city do to manage their children's asthma amidst these challenges. METHODS: African American parents of children aged 5 to 12 years diagnosed with persistent asthma living in the inner city were interviewed using a semistructured interview guide. Grounded theory analysis identified recurrent themes in the interview data. FINDINGS: Parents identified four adaptive routines they use to manage their children's asthma: ( 1 ) give young children with asthma responsibility for medication use; ( 2 ) monitor the availability of the school nurse; ( 3 ) manage air quality; and ( 4 ) frequently clean the home. These routines are described as adaptive because parents navigate ecological barriers and social forces within their daily context to manage their children's asthma. IMPLICATIONS: The authors argue that the first step in reducing the impact of ecological barriers is understanding African Americans' sociohistorical context.

A narrative of resistance: presentation of self when parenting children with asthma.

Using a social constructivist perspective and narrative analysis, the purpose of this paper is to illustrate how an understanding of self-presentation in interactions may inform health care interventions. We examine how a single African American mother, living in poverty, presents her sense of self in the context of obtaining and providing asthma care for her children. By analyzing four separate encounters--two interviews with the children's mother, the clinical encounter between the mother and her children's doctor, and an interview with the doctor, we gain an understanding of the mother's self-presentation and identity and the doctor's view of the mother. The analyses reveal the mother's consistent desire to protect her children in an unpredictable social world. By examining self-presentation, behavior that is typically construed as non-adherence is reframed as resilience, one mother's attempt to assert control. We argue that an understanding of identity production may enable practitioners and patients to create collaborative interventions. The analysis presented in this paper points to the need for a co-constructed intervention that allows for choice and control and honors the mother's sense of self.

Patterns of concordance and non-concordance with clinician recommendations and parents' explanatory models in children with asthma.

OBJECTIVE: Many children with asthma do not take medications as prescribed. We studied parents of children with asthma to define patterns of non-concordance between families' use of asthma controller medications and clinicians' recommendations, examine parents' explanatory models (EMs) of asthma, and describe relationships between patterns of non-concordance and EM. METHODS: Qualitative study using semi-structured interviews with parents of children with persistent asthma. Grounded theory analysis identified recurrent themes and relationships between reported medication use, EMs, and other factors. RESULTS: Twelve of the 37 parents reported non-concordance with providers' recommendations. Three types of non-concordance were identified: unintentional--parents believed they were following recommendations; unplanned--parents reported intending to give controller medications but could not; and intentional--parents stated giving medication was the wrong course of action. Analysis revealed two EMs of asthma: chronic--parents believed their child always has asthma; and intermittent--parents believed asthma was a problem their child sometimes developed. CONCLUSIONS: Concordance or non-concordance with recommended use of medications were related to EM's and family context and took on three different patterns associated with medication underuse. PRACTICE IMPLICATIONS: Efforts to reduce medication underuse in children with asthma may be optimized by identifying different types of non-concordance and tailoring interventions accordingly.