Becoming JEDI Warriors in Physical Therapy Research: A Multifaceted Approach.

The COVID-19 pandemic and recent incidents of social injustice exposed the systemic racism and discrimination in health care and clinical research that perpetuate systemic inequities. This perspective utilizes the acronym JEDI (justice, equity, diversity, and inclusion) as a vision for addressing inequities in physical therapy research. The need to go beyond diversity and focus on inclusion, equity, and justice is emphasized to achieve transformation within physical therapy research. The prevailing research paradigms are examined, acknowledging that research can perpetuate inequities and reinforcing the importance of integrating JEDI principles into the research process. The underrepresentation of diverse researchers in physical therapy is discussed, as well as the barriers faced by underrepresented researchers and research participants. Funding disparities are also highlighted, emphasizing the need for JEDI principles in research funding practices. How other health professions' associations are addressing JEDI in research is also explored. The authors propose a framework for action, utilizing the concepts of the socioecological model to identify gaps in JEDI within physical therapy research at different levels of influence and conclude by emphasizing the importance of justice in dismantling inequitable systems and urge the physical therapy research community to become JEDI warriors to bring about transformative change. IMPACT: By championing cultures that value justice, equity, diversity, and inclusion, individuals within the physical therapy research community have the potential to ignite a powerful transformation in society. The authors envision a future where JEDI warriors emerge, embracing the spirit of "Do or do not. There is no try," to forge a research community that is inclusive for all.1 Drawing inspiration from this mindset, this perspective seeks to empower individuals to harness the force of a JEDI warrior, fostering cultures that value justice, embrace inclusive methodologies, and ensure equitable access to resources and opportunities for researchers and participants.

Change in general and domain-specific physical activity during the transition from primary to secondary education: a systematic review.

BACKGROUND: Knowledge of changes in the domains of physical activity (PA) during the transition period from primary to secondary education and the factors associated with these changes, are prerequisites for the design of effective PA promotion strategies. Therefore, the first aim of this study was to systematically review changes in general, leisure-time, school, transport, work, and home PA across the transition from primary to secondary education. The second aim was to systematically review the individual, social, and physical environmental factors that were associated with these changes. METHODS: Records published up until September 2023 were retrieved from five electronic databases. We included longitudinal and cross-sectional studies that investigated general or domain-specific PA from 2 years before to 2 years after the transition from primary to secondary education. Information on source, study characteristics, sample characteristics, PA, and factors were extracted from the papers included. We reported the direction of change in general and domain-specific PA and the direction of association of the factors with change in general and domain-specific PA. RESULTS: Forty-eight papers were included in the study. The evidence on changes in PA and associated factors was greatest for general PA. A limited number of the studies investigated the separate domains of leisure-time, school, and transport. Most studies on general and school PA reported a decline in PA, but there were no consistent results for the domains of leisure-time and transport. With respect to the associated factors, evidence was predominantly found for individual factors and to a lesser degree for physical environmental and social environmental factors. None of the factors were consistently associated with changes in general or domain-specific PA during the school transition. CONCLUSIONS: For the design of targeted PA promotion strategies, further studies are warranted to explore changes in the specific domains of PA across the transition from primary to secondary education, especially in the domains of leisure-time, transport, home, and work PA. In addition, the interactions between factors at different socioecological levels to influence changes in PA need to be addressed more in the future. TRIAL REGISTRATION: PROSPERO CRD42020190204.

Key informants perspectives on creating a high impact research department in family and community medicine: a qualitative project.

BACKGROUND: Primary care is integral to the health system and population health. Primary care research is still in development and most academic departments lack effective research investments. High impact primary care research programs are needed to advance the field to ensure a robust primary care system for the future. The project objective was to understand key informants' views of structures, functions, and processes required to create a high impact research program in an academic primary care department. METHODS: A descriptive qualitative project with key informants from research programs in primary care. Participants included international research leaders in primary care (n = 10), department of family and community researchers (n = 37) and staff (n = 9) in an academic primary care department, other university leaders (n = 3) and members of the departmental executive leadership team (1 department; 25 members). Semi-structured interviews (n = 27), and focus groups (n = 6) were audio recorded, transcribed, and analyzed using thematic analysis. We used a socioecological framework which described micro, meso, macro levels of influence. RESULTS: At the micro level despite barriers with respect to funding, protected time and lack of formal mentorship, personal motivation was a key factor. At the meso level, the organizational structure that promoted collaboration and a sense of connection emerged as a key factor. Specifically research leaders identified a research faculty development pipeline based on equity, diversity, inclusion, indigeneity, and accessibility principles with thematic areas of focus as key enablers. Lastly, at the macro level, an overarching culture and policies that promoted funding and primary care research was associated with high impact programs. CONCLUSION: The alignment/complementarity of micro, meso, and macro level factors influenced the creation of a high impact research department in primary care. High impact research in primary care is facilitated by the development of researchers through formalized and structured mentorship/sponsorship and a department culture that promote primary care research.

Using the Socioecological Model to Explore Barriers to Health Care Provision in Underserved Communities in the Philippines: Qualitative Study.

BACKGROUND: The Philippines' primary care is delivered via local health centers called barangay health centers (BHCs). Barangays are the most local government units in the Philippines. Designed to promote and prevent disease via basic health care, these BHCs are staffed mainly by barangay health workers (BHWs). However, there has been limited research on the social and environmental factors affecting underserved communities' access to health care in underserved areas of the Philippines. Given the importance of BHCs in disease prevention and health promotion, it is necessary to identify obstacles to providing their services and initiatives. OBJECTIVE: This study aimed to explore multilevel barriers to accessing and providing basic health care in BHCs. METHODS: We used a qualitative approach and the socioecological model as a framework to investigate the multilevel barriers affecting basic health care provision. A total of 18 BHWs from 6 BHCs nationwide participated in focus group interviews. Traditional thematic content analysis was used to analyze the focus group data. After that, we conducted individual semistructured interviews with 4 public health nurses who supervised the BHWs to confirm findings from focus groups as a data source triangulation. The final stage of thematic analysis was conducted using the socioecological model as the framework. RESULTS: Findings revealed various barriers at the individual (lack of staff motivation and misperceptions of health care needs), interpersonal (lack of training, unprofessional behaviors, and lack of communication), institutional (lack of human resources for health, lack of accountability of staff, unrealistic expectations, and lack of physical space or supplies), community (lack of community support, lack of availability of appropriate resources, and belief in traditional healers), and policy (lack of uniformity in policies and resources and lack of a functional infrastructure) levels. CONCLUSIONS: Examining individual-, interpersonal-, institutional-, community-, and policy-level determinants that affect BHCs can inform community-based health promotion interventions for the country's underserved communities. Given the multidimensional barriers identified, a comprehensive program must be developed and implemented in collaboration with health care providers, community leaders, local and regional health care department representatives, and policy makers.

Application of the ConNECT Framework to achieve digital health equity.

BACKGROUND: The emphasis on digital technology and informatics in health care (digital health) has introduced innovative ways to deliver health care and engage populations in health research. However, inadequate attention to the development and implementation of digital health interventions can exacerbate health disparities. PURPOSE: We applied the transdisciplinary ConNECT Framework principles within the context of digital health, with an aim to describe strategies to achieve digital health equity. METHODS: We described the five ConNECT principles of (a) integrating context, (b) fostering a norm of inclusion, (c) ensuring equitable diffusion of innovations, (d) harnessing communication technology, and (e) prioritizing specialized training within the framework of achieving digital health equity. FINDINGS AND DISCUSSION: We describe proactive, actionable strategies for the systematic application of the ConNECT Framework principles to address digital health equity. Recommendations to reduce the digital health divide in nursing research and practice are also described.

Socioecological Predictors of Change in Adolescent Tobacco Use Across Waves 1-4 of the Population Assessment of Tobacco and Health Study.

BACKGROUND: Despite decreases in adolescents' cigarette use over the past decade, overall rates of adolescent tobacco use have increased. Research examining adolescents' changes across a range of tobacco products reflective of the current market, as well as multilevel predictors of use trajectories is needed. METHODS: Data derive from Waves 1-4 (W1-4; 2013-2018) of the Population Assessment of Tobacco and Health (PATH) study. Participants included 975 adolescents who used ≥1 tobacco product (cigarettes, electronic cigarettes [ECIGs], traditional cigars, cigarillos, filtered cigars, snus, smokeless tobacco [SLT], hookah) at any wave (W1 Mage = 13.29 [0.86], 54.2% male; 54.5% White, 25.9% Hispanic). RESULTS: Utilizing latent growth curve modeling (separate models per product), adolescents displayed increases in their past 30-day use of all tobacco products from W1-4. Greater W1 use was predicted by identifying as non-Hispanic (cigarettes); lower parent education (SLT); greater externalizing problems (cigarillos); greater motives (all products except cigarillos); greater youth-reported household smoking rules (cigarillos); and greater isolation (ECIGs). More use across time (i.e., higher slope) was predicted by older age (cigarettes); identifying as male (ECIGs, SLT), Black (vs. White; cigarillos), White (vs. Black, Hispanic; ECIGs, SLT); fewer externalizing problems (SLT); fewer motives (ECIGs); fewer youth-reported rules (cigarillos, SLT); and greater geographic isolation (cigarettes, SLT). DISCUSSION: Although some individual-level factors (i.e., motives, externalizing problems) predicted greater W1 use (i.e., intercept) only, interpersonal- (parent rules) and community-level (geographic isolation) factors were associated with changes in use over time (i.e., slope). Intervention efforts may address such factors to reduce adolescents' escalations in use.

Older Adults' Biobehavioral Fall Risks Were Affected by the COVID-19 Pandemic: Lessons Learned for Future Fall Prevention Research to Incorporate Multilevel Perspectives.

Background and Objectives: Examining the impact of coronavirus disease 2019 (COVID-19) pandemic on fall risks may provide insight into how multilevel factors as described in National Institute of Nursing Research's (NINR's) draft strategic plan can guide future fall prevention research. This article describes the affect of COVID-19 on fall risks from the perspective of older adults who live in assisted living facilities (ALFs), and explores the needs and approaches to implement fall prevention interventions at individual, social, community, and policy levels. Research Design and Methods: Exploratory survey study. Participants from a fall prevention study at 2 ALFs in Oregon were invited to the study. Survey questions asked about COVID experience, and changes in fall risks and day-to-day activities in Spring 2020. Quantitative responses were analyzed using descriptive statistics and Cohen's d effect sizes. Qualitative responses were analyzed using conventional content analysis. Results: Thirteen participants (age: M = 87.08, standard deviation = 6.52) responded. More participants reported feeling unsteady compared to pre-COVID data (38% vs. 62%), while the proportion of those worried about falling remained the same at 38%. Participants reported negligible decreases in importance of fall prevention and small decreases in confidence of fall prevention (Cohen's d = -0.13 and -0.21, respectively). The themes related to the affect of COVID on fall risks were: not to worry about fall risks but be cautious and physical activity is important, but it's hard during COVID. Impact of COVID on day-to-day activities were: varying degrees of concern for COVID, lack of social and community support, and finding unique ways to cope with COVID. Discussion and Implications: These individual-level perspectives suggest that older adults were at increased risk for falling. Results exemplify the influence of broader-level factors (e.g., social, community, and policy) on individual biobehavioral factors (e.g., fall risks and health behaviors), and illustrate the value of examining multilevel factors in future fall prevention research.

Exploring Female University Students' Participation in Physical Activity in Saudi Arabia: A Mixed-Methods Study.

Background: The importance of physical activity in improving physical and mental health has been emphasized in many studies. Researchers in Saudi Arabia have reported an increase in physical inactivity among Saudis, especially among University female population. Current efforts in the field in Saudi Arabia have yet to explore barriers and facilitators that influence female University student's participation in physical activity. This study aims to provide an assessment of the situation regarding physical activity among female University students in Saudi Arabia. Methods: This mixed method study preceded a participatory action research initiative. The first part of the mixed method consisted of a cross-sectional survey of 375 female University students in Saudi Arabia who completed the short form of the International Physical Activity Questionnaire. The second part consisted of semi-structured, in-depth interviews with 14 female University students and 16 female exercise trainers. Results: Results showed that most participants (91%) spent more time in walking activity compared to moderate (66%) and vigorous activity (57%) for at least 10 min at a time over a period of 7 days. Results showed that 70% of participants did not meet the WHO recommendation of 150 min per week of moderate activity, while around 62% of participants did not meet the WHO recommendation of 75 min per week of vigorous activity. Barriers to participation included limited facilities for physical activities, academic workload, gender role, and the need to adhere to cultural standards. Facilitators included valuing positive results, general health concerns, and family support. Conclusion: Knowledge gained from this study might support organizations and public health authorities to develop physical activity interventions that better address Saudi women's perceived needs. These findings are an important contribution to current knowledge in light of recent advances in women's rights in Saudi Arabia.

Medication Adherence in Type 2 Diabetes Mellitus: A Qualitative Exploration of Barriers and Facilitators From Socioecological Perspectives.

Adherence to antidiabetic medications (ADMs) remains a serious challenge among type 2 diabetes mellitus (T2DM) patients. Factors affecting medication adherence are not fully understood in Nigeria. This qualitative study explored patients' views on barriers and facilitators of medication adherence. Data collection was through face-to-face, semistructured, in-depth interviews conducted on 25 purposively sampled patients attending a public tertiary hospital. The interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis based on socioecological framework. NVIVO version 10 identified more codes. Most commonly identified barriers were organizational (clinic structure), personal (perception of T2DM as a dangerous illness), interpersonal (lack of spousal support), and community (concerns about taking ADMs in social gatherings). It was observed that female patients received more spousal support than the males. The facilitators of adherence include perceiving medication-taking a routine, the need to live longer, having savings for ADMs, purchasing medications to last until the next clinic visit. This study identified barriers and facilitators unique to Nigerian T2DM patients. Interventions anchored on these factors would improve medication adherence.

'[The pediatrician] said that maybe my milk, instead of doing good, no longer helped': the ecology of infant formula in rural communities in Central Mexico.

OBJECTIVE: As Mexico continues to develop, an epidemiological and nutritional transition has led to an increase in infant formula use in its rural and indigenous communities. Our objective was to determine the social and cultural factors that influence the use of formula in such populations in Central Mexico. DESIGN: Qualitative study using a data collection instrument based on the socio-ecological framework. SETTING: Two rural and indigenous communities in Central Mexico. PARTICIPANTS: Mothers, fathers, grandparents and healthcare providers. RESULTS: Breast-feeding was favoured in both communities; however, several cultural traditions hindered exclusive breast-feeding. As these communities became more developed, emerging ideas of modernity led to negative connotations about breast-feeding and many mothers began to view formula as a complement for breast-feeding. Formula was seen as a convenient solution for breast pain, insufficient milk and body image. Healthcare providers promoted the use of formula through their own beliefs, information, communication and conflicts of interest with formula industry representatives. The recent social and economic changes in these communities combined with the increased advertising and availability of breast milk substitutes have facilitated the preference for formula. CONCLUSIONS: Women in rural, indigenous communities in Central Mexico are increasingly using formula. Efforts at the policy and institutional levels are needed to protect mothers and their children from the detrimental consequences of unregulated formula promotion and the formula culture that it brings with it.

Longitudinal analysis of Socioecological obesogenic factors in a National Sample of U.S. children.

BACKGROUND: Childhood obesity is a serious public health threat. Although many researchers conducted research on socioecological determinants of childhood obesity, their longitudinal effects remain inconclusive especially among young children. This study examined socioecological factors and associated transitions of children's body mass index (BMI) status throughout children's kindergarten to elementary school years, using data from a national longitudinal sample. METHODS: The baseline sample of this study included 1264 children (weighted N = 379,297) extracted from the Early Childhood Longitudinal Study (baseline mean age: 5.24 years). The socioecological framework guided selection of socioecological obesogenic variables (e.g., family activity and parental involvement). Longitudinal ordered logistic regressions were performed to determine the associations between socioecological obesogenic variables and unhealthy/healthy changes in BMI status that captured transitions between healthy and unhealthy weight status (i.e., overweight, obesity, and severe obesity). RESULTS: Children with Hispanic ethnicity and nonwhite, less socioeconomic and environmental support, and living in households with fewer family members were more likely than their counterparts to have unhealthy BMI status changes over time (all ps < 0.05). Over the study period, girls were less likely than boys to experience transitions to unhealthy BMI status (all ps < 0.05). CONCLUSION: As hypothesized a priori, the findings of the current affirmed multiple dimensions of how sociological obesogenic factors may influence children's BMI status changes in a longitudinal setting. In order to maintain children's long-term healthy weight, more attention should be paid to socioeconomic obesogenic factors surrounding children as well as individual determinants of obesity (e.g., being physically active and having well-balanced nutrition).

Emergency Action Plans in Secondary Schools: Barriers, Facilitators, and Social Determinants Affecting Implementation.

CONTEXT: Secondary schools (SSs) inconsistently adopt emergency action plans (EAPs) for athletics. OBJECTIVE: To describe the barriers, facilitators, and social determinants influencing EAP adoption in SSs in the United States. DESIGN: Cross-sectional study. SETTING: Secondary schools. PATIENTS OR OTHER PARTICIPANTS: A national sample of athletic trainers (ATs; n = 9642) and athletic directors (ADs; n = 9687) were invited to participate in a Web-based questionnaire. A total of 1273 (13.2%) ATs and 702 (9.2%) ADs responded to the survey. MAIN OUTCOME MEASURE(S): The questionnaire addressed self-reported barriers to, facilitators of, and social determinants (eg, locale, funding classification [eg, public or private SS]) of EAP adoption. The responses of ATs and ADs were analyzed separately. Barriers, facilitators, and social determinants were evaluated using descriptive statistics. Contingency (2 × 2) tables were used to calculate the odds ratios (ORs) of adopting an EAP and the presence of each social determinant. RESULTS: Perceived barriers to implementation were a lack of knowledge about how to implement an EAP and financial limitations. Facilitators were having access to health care personnel, state mandates, and support from a person in an authoritative position. Compared with ATs at rural schools, ATs at suburban schools displayed greater odds of having an EAP (χ2 = 5.63, P = .01, OR = 1.63 [95% confidence interval = 1.08, 2.44]). According to the ADs' responses, a larger SS enrollment (≥500) led to greater odds of adopting an EAP (OR = 2.02 [95% confidence interval = 1.41, 2.89]). CONCLUSIONS: Perceived barriers to EAP adoption suggest that ATs and ADs need to be educated so they can provide additional information on the low cost of EAP adoption. Further, ADs described state mandates as facilitators to improve EAP adoption; therefore, efforts to educate state leaders about the need for mandated policies may be warranted. Certain social determinants (eg, school enrollment) may affect EAP adoption, but not every proposed determinant significantly affected adoption.

Perceived barriers to early detection of breast cancer in Wakiso District, Uganda using a socioecological approach.

BACKGROUND: Early detection of breast cancer is known to improve its prognosis. However, women in most low and middle income countries, including Uganda, do not detect it early hence present at an advanced stage. This study investigated the perceived barriers to early detection of breast cancer in Wakiso district, Uganda using a multilevel approach focused through a socioecological framework. METHODS: Using qualitative methods, participants were purposively selected to take part in the study. 5 semi-structured interviews were conducted among the community members while two focus groups were conducted amongst women's group and community health workers (CHWs) in Ssisa sub county, Wakiso district. In addition, 7 key informant interviews with health professionals, policy makers and public health researchers were carried out. RESULTS: Findings from the study revealed that barriers to early detection of breast cancer are multifaceted and complex, cutting across individual, interpersonal, organizational, community and policy barriers. The major themes that emerged from the study included: knowledge, attitudes, beliefs and practices (KABP); health system and policy constraints; and structural barriers. Prominent barriers associated with KABP were low knowledge, apathy, fear and poor health seeking behaviours. Barriers within the health systems and policy arenas were mostly centred around competing health care burdens within the country, lack of a cancer policy and weak primary health care capacity in Wakiso district. Distance, poverty and limited access to media were identified as the most prominent structural barriers. CONCLUSION: Barriers to early detection of breast cancer are complex and go beyond individual behaviours. These barriers interact across multiple levels of influence such as organizational, community and policy. The findings of this study could provide opportunities for investment in multi-level interventions.

Identifying Those Whom Health Promotion Hardly Reaches: A Systematic Review.

To understand what circumstances lend groups to be recognized as hardly reached by health services and research, we systematically reviewed studies that identified their priority populations as hard to reach. We classified attributes of hardly reached groups into cultural/environmental, individual, and demographic domains. Of the 334 identified studies, 78.74% used attributes that were classified into the cultural/environmental, 74.85% the individual, and 50% the demographic domain to identify those hardly reached. Of all possible combinations of domains, the most common was the use of all three domains (28.74%). Overall, papers were more likely to use attributes to identify their hardly reached population that fell into more than one domain (74.85%) compared to only one domain (25.15%; χ(2), p < .0001). Through this review, we identified the attributes of those who have been identified as hardly reached in published research. No single attribute is used to identify those who are hardly reached. This reflects a socioecological perspective, emphasizing that both intrapersonal and external elements may cause interventions to fail to reach those intended. Moreover, the focus not on populations hardly reached but on the attributes of those hardly reached suggests objectives for interventions to reach them better.