A community led innovation benefiting women and children: Health facilities and credit cooperative work together to promote maternal health care in Sahare VDC, Nepal.

Monetary incentives effectively promote antenatal care (ANC) attendance. However, in Nepal, late release of incentives is common, which leads to delays in payment to mothers, thereby negating the intended motivation. We evaluate a novel innovation where community organizers partnered with a Women's Saving and Credit Cooperative to provide interest-free loans for timely distribution to mothers. Through focus group discussions and interviews we found that monetary incentives motivate women to seek ANC services and timely incentives provide critical commodities postpartum. This qualitative evaluation shows the importance of timeliness in delivery of incentives and demonstrates the success of a community partnership innovation.

A qualitative analysis of smokers' perceptions about lung cancer screening.

BACKGROUND: In 2013, the US Preventive Services Task Force (USPSTF) began recommending lung cancer screening for high risk smokers aged 55-80 years using low-dose computed tomography (CT) scan. In light of these updated recommendations, there is a need to understand smokers' knowledge of and experiences with lung cancer screening in order to inform the design of patient education and tobacco cessation programs. The purpose of this study is to describe results of a qualitative study examining smokers' perceptions around lung cancer screening tests. METHODS: In 2009, prior to the release of the updated USPSTF recommendations, we conducted 12 120-min, gender-specific focus groups with 105 current smokers in Charlotte, North Carolina and Cincinnati, Ohio. Focus group facilitators asked participants about their experience with three lung cancer screening tests, including CT scan, chest x-ray, and sputum cytology. Focus group transcripts were transcribed and qualitatively analyzed using constant comparative methods. RESULTS: Participants were 41-67 years-old, with a mean smoking history of 38.9 pack-years. Overall, 34.3% would meet the USPSTF's current eligibility criteria for screening. Most participants were unaware of all three lung cancer screening tests. The few participants who had been screened recalled limited information about the test. Nevertheless, many participants expressed a strong desire to pursue lung cancer screening. Using the social ecological model for health promotion, we identified potential barriers to lung cancer screening at the 1) health care system level (cost of procedure, confusion around results), 2) cultural level (fatalistic beliefs, distrust of medical system), and 3) individual level (lack of knowledge, denial of risk, concerns about the procedure). Although this study was conducted prior to the updated USPSTF recommendations, these findings provide a baseline for future studies examining smokers' perceptions of lung cancer screening. CONCLUSION: We recommend clear and patient-friendly educational tools to improve patient understanding of screening risks and benefits and the use of best practices to help smokers quit. Further qualitative studies are needed to assess changes in smokers' perceptions as lung cancer screening with CT scan becomes more widely used in community practice.

Folic Acid Supplementation for the Prevention of Neural Tube Defects: An Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Neural tube defects are among the most common congenital anomalies in the United States. Periconceptional folic acid supplementation is a primary care-relevant preventive intervention. Objective: To review the evidence on folic acid supplementation for preventing neural tube defects to inform the US Preventive Services Task Force for an updated Recommendation Statement. Data Sources: MEDLINE, Cochrane Library, EMBASE, and trial registries through January 28, 2016, with ongoing surveillance through November 11, 2016; references; experts. Study Selection: English-language studies of folic acid supplementation in women. Excluded were poor-quality studies; studies of prepubertal girls, men, women without the potential for childbearing, and neural tube defect recurrence; and studies conducted in developing countries. Data Extraction and Synthesis: Two investigators independently reviewed abstracts, full-text articles, and risk of bias of included studies. One investigator extracted data and a second checked accuracy. Because of heterogeneity, data were not pooled. Main Outcomes and Measures: Neural tube defects, harms of treatment (twinning, respiratory outcomes). Results: A total of 24 studies (N > 58 860) were included. In 1 randomized clinical trial from Hungary initiated in 1984, incidence of neural tube defects for folic acid supplementation compared with trace element supplementation was 0% vs 0.25% (Peto odds ratio [OR], 0.13 [95% CI, 0.03-0.65]; n = 4862). Odds ratios from cohort studies recruiting participants between 1984 and 1996 demonstrated beneficial associations and ranged from 0.11 to 0.27 (n = 19 982). Three of 4 case-control studies with data from 1976 through 1998 reported ORs ranging from 0.6 to 0.7 (n > 7121). Evidence of benefit led to food fortification in the United States beginning in 1998, after which no new prospective studies have been conducted. More recent case-control studies drawing from data collected after 1998 have not demonstrated a protective association consistently with folic acid supplementation, with ORs ranging from 0.93 to 1.4 and confidence intervals spanning the null (n > 13 990). Regarding harms, 1 trial (OR, 1.40 [95% CI, 0.89-2.21]; n = 4767) and 1 cohort study (OR, 1.04 [95% CI, 0.91-1.18]; n = 2620) found no statistically significant increased risk of twinning. Three systematic reviews found no consistent evidence of increased risk of asthma (OR, 1.06 [95% CI, 0.99-1.14]; n = 14 438), wheezing, or allergy. Conclusions and Relevance: In studies conducted before the initiation of food fortification in the United States in 1998, folic acid supplementation provided protection against neural tube defects. Newer postfortification studies have not demonstrated a protective association but have the potential for misclassification and recall bias, which can attenuate the measured association of folic acid supplementation with neural tube defects.

A Review on Spinal Muscular Atrophy: Awareness, Knowledge, and Attitudes.

Spinal Muscular Atrophy (SMA) is one of the most common genetic causes of infant death. There is presently no cure, but the therapeutic pipeline is promising. Given the prevalence of SMA coupled with the potential for new treatment options, universal carrier screening, and newborn screening, we conducted a literature review of the awareness, knowledge, and attitudes held by the public and non-geneticist clinicians about various aspects of SMA. We then identify recommendations for targeting additional research, training, and educational efforts to increase awareness. In the limited available literature, we found that the public is generally unfamiliar with SMA but has favorable views of carrier and newborn screening. Clinicians also had limited understanding of SMA. Further research into knowledge and attitudes of healthcare providers and the general public will help develop a better understanding of education gaps and inform outreach efforts. These educational efforts are needed to complement the momentum as treatments are being developed and tested. Furthermore, professional societies are proposing routine carrier screening and SMA may achieve newborn screening status, which will change the SMA landscape for genetics professionals and families. Thus, it is important to explore knowledge and attitudes about SMA to allow us to prepare for when SMA attains higher public and clinician recognition.

Preferences for patient medication information: what do patients want?

This study investigated respondent preferences on how best to display patient medication information (PMI) that accompanies prescription medications to promote comprehension and appropriate usage. The authors identified 30 individuals diagnosed with select immune disorders, 30 with other chronic diseases, and 30 from the general public and had them review one of two PMI handouts that varied by format, organization, and content. The authors explored preferences for the PMI handout using one-on-one interviews. The authors analyzed the qualitative data to identify relevant themes and patterns using NVivo9 qualitative software. The majority of respondents noted that the formats of the two PMI handouts were more informative than those they currently receive from the pharmacist, with a preference for the 2-column, segmented design. However, respondent PMI preferences varied by age, education, and health status. Patients need simpler and more concise drug information to make better decisions about their health. Current PMI handouts are dense and complex, which can be confusing and not reader friendly. To improve PMI understandability and usefulness, the U.S. Food and Drug Administration is working with stakeholders, consumer advocates, and academics. Findings from this study may help inform future development of more user-friendly PMI.

The efficacy and cost-effectiveness of a community weight management intervention: a randomized controlled trial of the health weight management demonstration.

PURPOSE: The study investigated the efficacy and cost-effectiveness of a cognitive-behavioral weight management program, complemented by an interactive Web site and brief telephone/e-mail coaching. METHODS: In 2006-2007, 1755 overweight, non-active-duty TRICARE beneficiaries were randomized to one of three conditions with increasing intervention intensity: written materials and basic Web access (RCT1), plus an interactive Web site (RCT2), plus brief telephone/e-mail coaching support (RCT3). The study assessed changes in weight, blood pressure, and physical activity from baseline to 6, 12, and 15-18 months. (Study retention was 31% at 12 months.) Average and incremental cost-effectiveness and cost-offset analyses were conducted. RESULTS: Participants experienced significant weight loss (-4.0%, -4.0%, and -5.3%, respectively, in each RCT group after 12 months and -3.5%, -3.8%, and -5.1%, respectively, after 15 to 18 months), increased physical activity, and decreased blood pressure. Cost-effectiveness ratios were $900 to $1100/quality-adjusted life year (QALY) for RCT1 and RCT2 and $1900/QALY for RCT3. The cost recovery period to the government was 3 years for RCTs 1 and 2 and 6 years for RCT3. CONCLUSION: A relatively inexpensive cognitive-behavioral weight management intervention improved patient outcomes. Extrapolation of savings for the entire TRICARE population would significantly reduce direct medical costs.

A qualitative analysis of lung cancer screening practices by primary care physicians.

Lung cancer is the leading cause of cancer death in the United States, but no scientific organization currently recommends screening because of limited evidence for its effectiveness. Despite this, physicians often order screening tests such as chest X-rays and computerized tomography scans for their patients. Limited information is available about how physicians decide when to order these tests. To identify factors that affect whether physicians' screen patients for lung cancer, we conducted five 75-min telephone-based focus groups with 28 US primary care physicians and used inductive qualitative research methods to analyze their responses. We identified seven factors that influenced these physicians' decisions about screening patients for lung cancer: (1) their perception of a screening test's effectiveness, (2) their attitude toward recommended screening guidelines, (3) their practice experience, (4) their perception of a patient's risk for lung cancer, (5) reimbursement and payment for screening, (6) their concern about litigation, and (7) whether a patient requested screening. Because these factors may have conflicting effects on physicians' decisions to order screening tests, physicians may struggle in determining when screening for lung cancer is appropriate. We recommend (1) more clinician education, beginning in medical school, about the existing evidence related to lung cancer screening, with emphasis on the benefit of and training in tobacco use prevention and cessation, (2) more patient education about the benefits and limitations of screening, (3) further studies about the effect of patients' requests to be screened on physicians' decisions to order screening tests, and (4) larger, quantitative studies to follow up on our formative data.

Understanding Participants' Perceptions of Access to and Satisfaction With Chronic Disease Prevention Programs.

Despite the promise of incentive-based chronic disease prevention programs, comprehensive evidence on their accessibility among low-income populations remains limited. We adapted Aday and Andersen's framework to examine accessibility and consumer satisfaction within the Medicaid Incentives for the Prevention of Chronic Disease (MIPCD) cross-site demonstration. MIPCD provided 10 states with 5-year grants to implement incentivized chronic disease prevention and management programs for low-income and/or disabled-Medicaid enrolled-Americans. We conducted 36 focus group discussions between July 2014 and December 2015 with Medicaid enrollees participating in the MIPCD programs. We assessed participants' satisfaction by program type (i.e., diabetes prevention, diabetes management, hypertension reduction, smoking cessation, and weight management) related to three components: program enrollment and participation, staff courtesy, and program convenience. Based on Aday and Andersen's framework, we conducted thematic analysis to determine similarities and differences across MIPCD programs by type. Participant feedback confirmed the importance of several features of the Aday and Andersen framework, particularly programs with easy enrollment and participation procedures, courteous and helpful staff, and those that are convenient and flexible for participants. Participants valued programming around the clock via telephone and flexible, in-person hours of operation as well as proximity of the program to reliable transportation. We observed that most participants, despite enrollment and participation barriers, perceived programs as accessible and were willing to engage and continue to participate. This finding may reflect behavior change theory's perspective on personal readiness to change. Individuals in the preparation stage of change can effectively change health habits despite barriers they may encounter. In some cases, personal readiness to change was more impactful than consumer satisfaction at encouraging ongoing participation and perceived access to the programs. Thus, program developers may want to consider individual participant readiness to change and its impact on consumer satisfaction when designing, implementing, and evaluating behavior change initiatives.

Satisfaction with Financial Incentives for Chronic Disease Prevention.

ObjectiveWe examined Medicaid enrollees' experiences and satisfaction with financial incentives-based chronic disease prevention programs in 10 states. MethodsThis cross-site study of the Medicaid Incentives for Prevention of Chronic Diseases model used a mixed-methods approach to assess Medicaid enrollees' experiences and satisfaction with the incentive programs. We conducted 31 in-person focus groups with 212 program participants, followed by a mail survey in English and Spanish (N = 2274). We used both the qualitative focus group data and the quantitative survey data to examine participant satisfaction with the incentives, along with differences by program and incentive characteristics. ResultsOverall, focus group and survey findings aligned, with participants reporting satisfaction with program incentives. Participants felt that the incentives helped them make positive changes to improve their health. Nevertheless, satisfaction varied considerably depending on characteristics of the program, such as the form and magnitude of the incentive, health focus of the program, and program delivery method. ConclusionsProgram and incentive characteristics play key roles in participants' satisfaction and experience with incentive-based, chronic disease prevention programs. Further research is required to examine the optimal design of incentive programs to support sustained behavior change.

Perceptions of emerging tobacco products and nicotine replacement therapy among pregnant women and women planning a pregnancy.

The increasing availability of emerging non-combusted tobacco products (snus, dissolvables, and electronic nicotine delivery systems or ENDS) may have implications for pregnant women and women of reproductive age. We conducted 15 focus groups to explore how women perceive emerging non-combusted tobacco products and nicotine replacement therapy (NRT) in general, and during pregnancy. Sessions were held in 2013 in four U.S. cities. Participants were 18-40 years old and were pregnant smokers, pregnant quitters, or smokers planning a pregnancy. Responses were coded and analyzed to identify key themes using NVivo 10.0 qualitative software (QSR). Several themes emerged from focus groups. Participants generally found snus unappealing, but viewed dissolvables as a discreet and stigma-free way to use tobacco during pregnancy. Participants perceived NRT as ineffective and having undesired side effects. ENDS were thought to offer advantages over cigarettes, including use in smoke-free areas, lower cost, appealing flavors, and fewer health effects, and were seen by some as a potential quit aid. Some participants, however, worried that the lack of natural stopping point could lead to excessive use. Many participants felt that the use of any tobacco or NRT product is harmful during pregnancy. Women seeking to reduce health risks or stigma related to smoking during pregnancy may perceive advantages of using some emerging products over cigarettes. These findings can inform future public health efforts to reduce risks associated with tobacco product use among women of reproductive age.

Examining Parents' Experiences and Information Needs Regarding Early Identification of Developmental Delays: Qualitative Research to Inform a Public Health Campaign.

OBJECTIVE: The purpose of this study was to assess the approach and materials of Centers for Disease Control and Prevention's "Learn the Signs. Act Early." (LTSAE) health education campaign, which aims to improve awareness of developmental milestones and early warning signs of developmental delay among parents of young children. METHODS: We conducted 2 phases of qualitative research. Focus groups assessed the campaign's objectives by exploring the experiences of parents with children who have developmental delays or disabilities to determine facilitators of and barriers to identification. In-depth interviews were conducted with parents of typically developing children, who reviewed campaign materials and provided feedback on appropriateness, appeal, and clarity with regard to the campaign's objectives. RESULTS: Phase 1: Parents were typically the first to express concern about their child's development, and most talked with their child's health care provider. Two categories of health care providers emerged: those who proactively asked about a child's development, used tools to facilitate conversations, and made referrals, and those who did not ask about development, told parents to "wait and see," and did not provide information about services and supports. Few parents knew about special education services before identification. Phase 2: Participants found the campaign materials appealing, but were unclear about how to act early and why acting early was important. CONCLUSIONS: Results affirmed LTSAE's evidence-based approach to educating parents about child development. Additional campaign considerations include providing more information about how to act early and why acting early is important and enhancing outreach to providers to help them communicate with concerned parents.

Understanding Women's Preconception Health Goals: Audience Segmentation Strategies for a Preconception Health Campaign.

This article discusses the social marketing planning process and strategies used to design a preconception health campaign, Show Your Love, launched in February 2013. Developing a social marketing strategy for preconception health is a challenging endeavor, in part because preconception health represents a set of diverse behaviors and the audience for the campaign is quite large, encompassing all women of childbearing age whether they intend to become pregnant or not. The network of organizations implementing the campaign, the National Preconception Health Consumer Workgroup, required a broad audience segmentation strategy; therefore, two large audiences were selected. This commentary describes the two primary audiences selected for the campaign based on the Transtheoretical Model-intenders (those in contemplation, preparation, and action) and nonintenders (precontemplators)-and explores how levels of knowledge, motivations, the campaign product, and the campaign goals are distinct for each audience. Additionally, the authors describe potential extensions to the segmentation strategy that could offer finer grained approaches for social marketers who may be building on the Show Your Love campaign or designing other programs in this area.

Couples' notions about preconception health: implications for framing social marketing plans.

PURPOSE: To understand couples' notions of preconception health (PCH) and to inform the development of social marketing plans focused on PCH. APPROACH/DESIGN: We used a social marketing perspective to understand how couples considered PCH as a product, its potential price, how it should be promoted, and in what type of places it should be promoted. These variables are typically referred to as the four social marketing P's. SETTING: Telephone interviews with couples recruited from a national database. PARTICIPANTS: A total of 58 couples (116 individuals) were segmented by five couple segments based on pregnancy planning intention and current parental status in which the wife or partner was 18 to 44 years of age. The five segments were combined into three categories: couples who were planning pregnancies, couples who were not planning pregnancies, or couples who were recent parents (interconception). METHOD: Couple-based structured interviews lasting approximately 45 to 60 minutes were conducted via telephone. Questions inquired about couples' experience with PCH and the four social marketing P's. RESULTS: Commonalities existed across the four social marketing P's for the different couple segments. Notable couple-related themes that emerged included the importance of couple communication, support, and relationship quality. PCH was more relevant for couples planning a pregnancy, but nonplanning couples understood the benefits of PCH and related behaviors. CONCLUSION: Couples may be an important target audience when considering social marketing approaches for PCH. Many couples perceived the relevance of the issue to important aspects of their lives, such as health, family, and their relationships.

Consumers' perceptions of preconception health.

PURPOSE: To inform the development of a preconception health (PCH) social marketing plan, we conducted qualitative research with prospective consumers. APPROACH: We present formative findings based on the four Ps of social marketing: product, price, promotion, and place. SETTING: We conducted focus groups with 10 groups of women in Atlanta, Georgia, in fall 2010. PARTICIPANTS: We classified women aged 18 to 44 into five groups based on their pregnancy plans, and then further segmented the groups based on socioeconomic status for a total of 10 groups. METHOD: The focus group guide was designed to elicit participants' responses about the product, price, promotion, and placement of PCH. We used NVivo 9 software to analyze focus group data. RESULTS: Women planning a pregnancy in the future had different perspectives on PCH as a product than women not planning a pregnancy. Barriers to PCH included lack of social support, addiction, and lack of awareness about PCH. Participants preferred to think of PCH behaviors as "promoting" a healthy baby rather than preventing an unhealthy birth outcome. Many women in the focus groups preferred to hear PCH messages from a health care provider, among other channels. CONCLUSION: The results from this research will inform the development of a social marketing plan for PCH and the development of concepts that will be tested with consumers to determine their viability for use in a national campaign.

Assessing the impact of user-centered research on a clinical trial eHealth tool via counterbalanced research design.

OBJECTIVE: Informatics applications have the potential to improve participation in clinical trials, but their design must be based on user-centered research. This research used a fully counterbalanced experimental design to investigate the effect of changes made to the original version of a website, http://BreastCancerTrials.org/, and confirm that the revised version addressed and reinforced patients' needs and expectations. DESIGN: Participants included women who had received a breast cancer diagnosis within the last 5 years (N=77). They were randomized into two groups: one group used and reviewed the original version first followed by the redesigned version, and the other group used and reviewed them in reverse order. MEASUREMENTS: The study used both quantitative and qualitative measures. During use, participants' click paths and general reactions were observed. After use, participants were asked to answer survey items and open-ended questions to indicate their reactions and which version they preferred and met their needs and expectations better. RESULTS: Overall, the revised version of the site was preferred and perceived to be clearer, easier to navigate, more trustworthy and credible, and more private and safe overall. However, users who viewed the original version last had similar attitudes toward both versions. CONCLUSION: By applying research findings to the redesign of a website for clinical trial searching, it was possible to re-engineer the interface to better support patients' decisions to participate in clinical trials. The mechanisms of action in this case appeared to revolve around creating an environment that supported a sense of personal control and decisional autonomy.

Patterns of prescribing antiepileptic drugs for bipolar disorder.

Off-label use of medications is the subject of great debate. Prescribing is influenced by a number of factors, including peer recommendations, pharmaceutical industry marketing, and evidence-based drug effectiveness reports. Understanding prescribing patterns for a particular drug class can inform efforts to provide fair and balanced information to prescribers. This study investigated four dimensions of psychiatrists' prescribing practices for antiepileptic drugs (AEDs) for bipolar disorder: 1) psychiatrists' current use of AEDs, 2) their actual and preferred sources of information on AEDs, 3) their knowledge about the Neurontin lawsuit, and 4) their reactions to sample marketing campaign materials, including key messages from an evidence-based report on the topic. Qualitative methods, including telephone and in-person focus groups and in-depth interviews, were used to explore these dimensions. We found that psychiatrists prescribe AEDs for off-label use, but that they are not using gabapentin as a primary treatment for bipolar disorder. The psychiatrists also reported that they obtained their information about AEDs from professional journals, colleagues, and pharmaceutical representatives. The psychiatrists were asked to review a set of four key messages derived from an evidence-based report on the use of AEDs to treat bipolar disorder. They had misconceptions about the efficacy of the draft messages as they were written, stating that they were oversimplified and erroneous. The messages were revised based on the participants' feedback. However, the core findings from the evidence-based report remained unchanged. Recommendations for developing and disseminating messages and materials for a future corrective marketing campaign to provide fair and balanced information to physicians about gabapentin and other AEDs are discussed.