Advancing Primary Care Access: Exploring the Impact of the Virtual Waiting Room on the Quadruple Aim.

BACKGROUND: Community health centers grapple with high no-show rates, posing challenges to patient access and primary care provider (PCP) utilization. AIM: To address these challenges, we implemented a virtual waiting room (VWR) program in April 2023 to enhance patient access and boost PCP utilization. SETTING: Academic community health center in a small urban city in Massachusetts. PARTICIPANTS: Community health patients (n = 8706) and PCP (n = 14). PROGRAM DESCRIPTION: The VWR program, initiated in April 2023, involved nurse triage of same-day visit requests for telehealth appropriateness, then placing patients in a standby pool to fill in as a telehealth visit for no-shows or last-minute cancellations in PCP schedules. PROGRAM EVALUATION: Post-implementation, clinic utilization rates between July and September improved from 75.2% in 2022 to 81.2% in 2023 (p < 0.01). PCP feedback was universally positive. Patients experienced a mean wait time of 1.9 h, offering a timely and convenient alternative to urgent care or the ER. DISCUSSION: The VWR is aligned with the quadruple aim of improving patient experience, population health, cost-effectiveness, and PCP satisfaction through improving same-day access and improving PCP schedule utilization. This innovative and reproducible approach in outpatient offices utilizing telehealth holds the potential for enhancing timely access across various medical disciplines.

Development and Validation of Prediction Models for the 5-year Risk of Type 2 Diabetes in a Japanese Population: Japan Public Health Center-based Prospective (JPHC) Diabetes Study.

BACKGROUND: This study aimed to develop models to predict the 5-year incidence of type 2 diabetes mellitus (T2DM) in a Japanese population and validate them externally in an independent Japanese population. METHODS: Data from 10,986 participants (aged 46-75 years) in the development cohort of the Japan Public Health Center-based Prospective Diabetes Study and 11,345 participants (aged 46-75 years) in the validation cohort of the Japan Epidemiology Collaboration on Occupational Health Study were used to develop and validate the risk scores in logistic regression models. RESULTS: We considered non-invasive (sex, body mass index, family history of diabetes mellitus, and diastolic blood pressure) and invasive (glycated hemoglobin [HbA1c] and fasting plasma glucose [FPG]) predictors to predict the 5-year probability of incident diabetes. The area under the receiver operating characteristic curve was 0.643 for the non-invasive risk model, 0.786 for the invasive risk model with HbA1c but not FPG, and 0.845 for the invasive risk model with HbA1c and FPG. The optimism for the performance of all models was small by internal validation. In the internal-external cross-validation, these models tended to show similar discriminative ability across different areas. The discriminative ability of each model was confirmed using external validation datasets. The invasive risk model with only HbA1c was well-calibrated in the validation cohort. CONCLUSION: Our invasive risk models are expected to discriminate between high- and low-risk individuals with T2DM in a Japanese population.

Patient-perceived barriers to early initiation of prenatal care at a large, urban federally qualified health center: a mixed-methods study.

BACKGROUND: Early initiation of prenatal care is widely accepted to improve the health outcomes of pregnancy for both mothers and their infants. Identification of the various barriers to entry into care that patients experience may inform and improve health care provision and, in turn, improve the patient's ability to receive necessary care. AIM: This study implements a mixed-methods approach to establish methods and procedures for identifying barriers to early entry to prenatal care in a medically-vulnerable patient population and areas for future quality improvement initiatives. METHODS: An initial chart review was conducted on obstetrics patients that initiated prenatal care after their first trimester at a large federally qualified health center in Brooklyn, NY, to determine patient-specified reasons for delay. A thematic analysis of these data was implemented in combination with both parametric and non-parametric analyses to characterize the population of interest, and to identify the primary determinants of delayed entry. RESULTS: The age of patients in the population of interest (n = 169) was bimodal, with a range of 15 - 43 years and a mean of 28 years. The mean gestational age of entry into prenatal care was 19 weeks. The chart review revealed that 8% recently moved to Brooklyn from outside of NYC or the USA. Nine percent had difficulty scheduling an initial prenatal visit within their first trimester. Teenage pregnancy accounted for 7%. Provider challenges with documentation (21%) were noted. The most common themes identified (n = 155) were the patient being in transition (21%), the pregnancy being unplanned (17%), and issues with linkage to care (15%), including no shows or patient cancellations. Patients who were late to prenatal care also differed from their peers dramatically, as they were more likely to be Spanish-speaking, to be young, and to experience a relatively long delay between pregnancy confirmation and entry into care. Moreover, the greatest determinant of delayed entry into care was patient age. CONCLUSION: Our study provides a process for other like clinics to identify patients who are at risk for delayed entry to prenatal care and highlight common barriers to entry. Future initiatives include the introduction of a smart data element to document reasons for delay and use of community health workers for dedicated outreach after no show appointments or patient cancellations.

Factors associated with prior completion of colorectal cancer and hepatitis C virus screenings among community health center patients: a cross-sectional study to inform a multi-behavioral educational intervention.

BACKGROUND: Colorectal cancer (CRC) and liver cancer are two of the leading causes of cancer death in the United States and persistent disparities in CRC and liver cancer incidence and outcomes exist. Chronic hepatitis C virus (HCV) infection is one of the main contributors to liver cancer. Effective screening for both CRC and HCV exist and are recommended for individuals based upon age, regardless of gender or sex assigned at birth. Recommendations for both screening behaviors have been recently updated. However, screening rates for both CRC and HCV are suboptimal. Targeting adoption of multiple screening behaviors has the potential to reduce cancer mortality and disparities. OBJECTIVE: To examine psychosocial factors associated with completion of CRC and HCV screenings in order to inform a multi-behavioral educational intervention that pairs CRC and HCV screening information. METHODS: A cross-sectional survey was conducted with participants (N = 50) recruited at two community health centers in Florida (United States). Kruskal-Wallis and Fisher's exact tests were used to examine associations between completion of both CRC and HCV screening, CRC and HCV knowledge, Preventive Health Model constructs (e.g., salience and coherence, response efficacy, social influence), and sociodemographic variables. RESULTS: Most participants were White (84%), female (56%), insured (80%), and reported a household income of $25,000 or less (53%). 30% reported ever previously completing both CRC and HCV screenings. Prior completion of both screening behaviors was associated with higher educational attainment (p = .014), having health insurance (p = .022), being U.S.-born (p = .043), and higher salience and coherence scores for CRC (p = .040) and HCV (p = .004). CONCLUSIONS: Findings demonstrate limited uptake of both CRC and HCV screenings among adults born between 1945 and 1965. Uptake was associated with multiple sociodemographic factors and health beliefs related to salience and coherence. Salience and coherence are modifiable factors associated with completion of both screening tests, suggesting the importance of incorporating these health beliefs in a multi-behavioral cancer education intervention. Additionally, health providers could simultaneously recommend and order CRC and HCV screening to improve uptake among this age cohort.

Level of technical efficiency and associated factors among health centers in East Gojjam Zone, Northwest Ethiopia: an application of the data envelopment analysis.

BACKGROUND: Besides the scarcity of resources, inefficient utilization of available health service resources has been the bottleneck to deliver quality health services in Ethiopia. However, Information regarding the efficiency of health service providers is limited in the country. Health service managers and policy makers must be well informed about the efficiency of health service providers and ways of using limited resources efficiently to make evidence-based decisions. This study aimed to assess the level of technical efficiency and associated factors among health centers in East Gojjam Zone, Northwest Ethiopia. METHODS: A facility-based cross-sectional study was conducted among 27 randomly selected health centers in East Gojjam zone, Northwest Ethiopia, from October 30, 2022, to April 30, 2023. Using an interviewer-administered questionnaire and document review checklist, health centers' data was collected and entered to Epi-Data version 4.6. The data was exported to Microsoft office excel and Stata version 14 for analysis. A two-stage output-oriented data envelopment analysis with a variable return to scale assumption was employed to determine the level of technical efficiencies. Finally, the tobit regression model was applied to identify the associated factors at 5% level of significance. RESULTS: In this study, 59.3% of the health centers were technically efficient. The mean technical efficiency score of the health centers was 0.899 ± 0.156. Inefficient health centers could provide more 22, 433 outpatient visits, 1,351 family planning visits, 155 referral services, 206 skilled deliveries and 385 fully vaccinations of children if they were technically efficient as their peer health centers for the same year. From the tobit regression, the catchment population and number of administrative staffs were statistically significant determinants of the technical efficiency of health centers. CONCLUSIONS: The mean technical efficiency of the health centers in East Gojjam zone, Northwest Ethiopia was high. However, nearly half of the health centers were technically inefficient, which indicates the exitance of a space for further improvements in the productivity of these health centers. Employing excess number administrative staffs (above the optimal level) should be discouraged and selecting appropriate sites where the health centers to be constructed (to have large catchment population coverage) could improve the productivity of health centers.

Application of the FRAME-IS to a multifaceted implementation strategy.

BACKGROUND: Research demonstrates the importance of documenting adaptations to implementation strategies that support integration of evidence-based interventions into practice. While studies have utilized the FRAME-IS [Framework for Reporting Adaptations and Modifications for Implementation Strategies] to collect structured adaptation data, they are limited by a focus on discrete implementation strategies (e.g., training), which do not reflect the complexity of multifaceted strategies like practice facilitation. In this paper, we apply the FRAME-IS to our trial evaluating the effectiveness of PF on implementation fidelity of an evidence-based technology-facilitated team care model for improved hypertension control within a federally qualified health center (FQHC). METHODS: Three data sources are used to document adaptations: (1) implementation committee meeting minutes, (2) narrative reports completed by practice facilitators, and (3) structured notes captured on root cause analysis and Plan-Do-Study-Act worksheets. Text was extracted from the data sources according to the FRAME-IS modules and inputted into a master matrix for content analysis by two authors; a third author conducted member checking and code validation. RESULTS: We modified the FRAME-IS to include part 2 of module 2 (what is modified) to add greater detail of the modified strategy, and a numbering system to track adaptations across the modules. This resulted in identification of 27 adaptations, of which 88.9% focused on supporting practices in identifying eligible patients and referring them to the intervention. About half (52.9%) of the adaptations were made to modify the context of the PF strategy to include a group-based format, add community health workers to the strategy, and to shift the implementation target to nurses. The adaptations were often widespread (83.9%), affecting all practices within the FQHC. While most adaptations were reactive (84.6%), they resulted from a systematic process of reviewing data captured by multiple sources. All adaptations included the FQHC in the decision-making process. CONCLUSION: With modifications, we demonstrate the ability to document our adaptation data across the FRAME-IS modules, attesting to its applicability and value for a range of implementation strategies. Based on our experiences, we recommend refinement of tracking systems to support more nimble and practical documentation of iterative, ongoing, and multifaceted adaptations. TRIAL REGISTRATION: Clinicaltrials.gov NCT03713515, Registration date: October 19, 2018.

Standardizing and Improving Primary Care-Based Electronic Developmental Screening for Young Children in Federally Qualified Health Center Clinics.

OBJECTIVES: Many barriers to implementation of developmental screening in primary care exist, especially for children from under-resourced communities. Developmental screening is vital to early detection of developmental delay and autism spectrum disorder, and early intervention (EI) referral. This study sought to examine whether implementation of a standardized clinical workflow using electronic screening tools improved both rates of developmental screening, and the number of children identified at risk for developmental delay, in a federally qualified health center (FQHC). METHODS: A retrospective study was conducted at an academic-affiliated FQHC. Electronic versions of the Ages and Stages Questionnaire 3 (ASQ-3) and Modified Checklist in Autism for Toddlers Revised (M-CHAT-R) were implemented at well-child visits. New clinical workflow training on developmental screening and EI referral was provided. Chi-square and Fisher's Exact analyses were conducted. RESULTS: ASQ-3 screening rates increased from 62.7 to 73.6% pre- to post-intervention. Post-intervention, there was a significant decrease in paper screens (p < .001), and a significant increase in the percentage of children with ASQ-3 results in the below cutoff range from 14.7 to 18.2% (p < .002). M-CHAT-R screening rates increased from 56.4 to 59.4% pre- to post-intervention. Post-intervention, there was a significant increase in electronic screens (p < .001). CONCLUSIONS FOR PRACTICE: Implementation of electronic screening tools improved universal developmental screening in a FQHC. To decrease barriers in under-resourced communities, the use of electronic tools may decrease the rate of screening error seen with paper screening and have the potential to better identify children at risk for developmental delay.

A Quality Improvement Approach to Increasing Access to long-Acting Reversible Contraceptives in a Federally Qualified Health Center.

OBJECTIVES: Long-acting reversible contraceptives (LARCs) are the most effective forms of contraception available and therefore play a critical role in supporting patients to exercise bodily autonomy and achieve reproductive goals. A comprehensive set of quality improvement (QI) interventions were implemented between March and June 2019 to improve LARC access at a federally qualified health center (FQHC) in (US State). METHODS: An evaluation study was conducted to assess the impact of the QI initiative considering the number of LARCS delivered as a proxy for access. The Wilcoxon-rank test was applied to test for significance, given a non-parametric sample of LARCs delivered by 13 providers (matched to themselves) pre- and post-intervention. Reimbursement for LARC procedures pre- and post-intervention was also examined to determine economic impact and sustainability of incorporating a new device, the Liletta™, in the floor stock. RESULTS: There was a statistically significant increase in LARC delivery between July 2019-March 2020 compared to July 2018-March 2019. Approximately $1,000 per month increased reimbursement for LARC services occurred post-intervention. The evaluation study concluded success of the QI intervention, with need for further study needed to determine equitable delivery of contraceptive services between different subpopulations and by insurance status. CONCLUSIONS FOR PRACTICE: The study provides a blueprint for QI initiatives to improve access to LARCs while also increasing revenue for LARC services in an FQHC setting.

Evaluating the Diagnostic Performance of Large Language Models on Complex Multimodal Medical Cases.

Large language models showed interpretative reasoning in solving diagnostically challenging medical cases.

Artificial Neural Network Analysis Examining Substance Use Problems Co-Occurring with Anxiety and Depressive Disorders Among Adults Receiving Mental Health Treatment.

Objective: The co-occurrence of anxiety disorders, depressive disorders, and substance use problems was examined. Methods: The Mental Health Client-Level Data dataset was used to conduct logistic regression models and an artificial neural network analysis. Logistic regression analyses were conducted among adults with anxiety (n = 547,473) or depressive disorders (n = 1,610,601) as their primary diagnosis who received treatment in a community mental health center. The artificial neural network analysis was conducted with the entire sample (N = 2,158,074). Results: Approximately 30% of the sample had co-occurring high-risk substance use or substance use disorder. Characteristics including region of treatment receipt, age, education, gender, race and ethnicity, and the presence of co-occurring anxiety and depressive disorders were associated with the co-occurring high-risk substance use or a substance use disorder. Conclusions: Findings from this study highlight the importance of mental health facilities to screen for and provide integrated treatment for co-occurring disorders.

Telemedicine Screening for Eye Disorders in Federally Qualified Health Centers: Relationship to Vision-Targeted Health-Related Quality of Life.

Introduction: Federally Qualified Health Centers (FQHCs) play a crucial role as safety-net primary health care clinics in the United States, serving medically underserved areas and populations. However, eye services are rarely offered at FQHCs. We examined how telemedicine-generated ocular diagnoses impacted vision-targeted health-related quality of life at FQHCs in rural Alabama. Methods: We focused on patients who are at risk for glaucoma. Both visual function and retinal imaging were assessed. The telemedicine vision screening protocol performed by a remote ophthalmologist evaluated eyes for glaucoma, diabetic retinopathy, cataract, age-related macular degeneration, and a measurement of habitual visual acuity. The National Eye Institute Visual Function Questionnaire-9 (VFQ-9) was administered. Results: Using stepwise regression, the best-fitting model for predicting VFQ-9 scores incorporated visual acuity 20/40 or worse, a diabetic retinopathy diagnosis, and sociodemographic variables (gender, transportation, insurance type/status, and employment status). Conclusion: Vision-targeted, health-related quality of life in our FQHC settings was related to the visual acuity impairment and the diagnosis of diabetic retinopathy but was also influenced by a variety of sociodemographic factors.

Effectiveness of Psychosocial Skills Training and Community Mental Health Services: A Qualitative Research.

This study employs a phenomenological approach to investigate the experiences of individuals who access services at a community mental health center (CHMC) in Türkiye The aim of this study is to comprehend the experiences of individuals who participate in psychosocial skills training at the CHMC. Thematic analysis of data from sixteen in-depth interviews revealed three main themes and eight sub-themes. Functionality theme emphasizes the positive impact of CHMC services and training on daily life and social functioning. Effective Factors theme encompasses the elements that improve the effectiveness of CHMC services. Participants have provided suggestions for the content of the training under the theme of Recommendations. Study results show that CHMC services and psychosocial skills training benefit individuals' daily lives and functioning, but that opportunities for improvement exist. It is crucial to incorporate participant feedback, and further research should be conducted to investigate the effectiveness of these services in this area.

Early Health Impacts of a Primary Care Consultation Model for People Served by Assertive Community Treatment teams.

The cardiometabolic health outcomes and life expectancy of people living with serious mental illness (SMI) continue to significantly flag behind that of the general population. This study explores the possibility of using the evidence-based Assertive Community Treatment (ACT) model and infrastructure to increase access to primary care and improve cardiometabolic outcomes of people with SMI. Four ACT teams in a large urban area received the services of a primary care consultant who was co-located at a Federally Qualified Health Center (FQHC), met regularly with ACT team clinicians to review a cardiometabolic registry of participants, and engaged participants in primary care services. Health screening rates, primary care utilization, and cardiometabolic outcomes-body mass index, blood pressure, hemoglobin A1c, cholesterol, and tobacco smoking status-were monitored over the course of a year. The efficacy of this integrated care model was also explored through focus groups with ACT team staff and participants. Significant improvements in screening rates were found for the ACT teams that received this integrated care intervention; however, only modest improvements in cardiometabolic outcomes were found. Future longitudinal, multi-site studies are needed to fully determine the impact of integrated care models on the physical health outcomes of this vulnerable population.

Evaluating health literacy from an organizational perspective: A cross-sectional study of community health centers.

OBJECTIVES: To investigate community health centers' (CHCs) health literacy. DESIGN: A cross-sectional study. SAMPLE: A total of 374 CHCs were surveyed and 258 CHCs responded, with an effective questionnaire response rate of 69.0%. MEASUREMENTS: Data were collected by using a self-developed health literacy assessment tool to survey CHCs' health literacy throughout Taiwan from January to December 2019. RESULTS: The item of organizational health literacy (OHL) with the highest proportion of CHCs not implementing them was "Design of easy-to-use computer applications and new media" (47.3% not yet achieved), followed by "Involving target audiences in document and service development" (34.9% not yet achieved). CHCs located in northern Taiwan had higher health literacy achievement scores than those in other regions, and those in urban areas had higher health literacy achievement scores than those in general and remote areas. CONCLUSIONS: This study identified items with poor implementation of OHL and found regional differences in health literacy among CHCs. The findings can inform the development of targeted interventions to improve health literacy in underperforming CHCs and guide policymakers in allocating resources to regions and areas in need of.

Hepatitis B vaccination coverage and associated factors among nurses working at health centers in Addis Ababa, Ethiopia: a cross-sectional study.

BACKGROUND: Hepatitis B virus (HBV) poses one of the most serious workplace health risks facing healthcare workers, especially nurses, due to occupational exposure. The HBV vaccination coverage among healthcare workers in Ethiopia ranged from 5.4 to 21.9%. However, little is known about HBV vaccination coverage and associated factors among nurses in Ethiopia. Therefore, the aim of this study was to assess HBV vaccination coverage and associated factors among nurses working in health centers in Addis Ababa, Ethiopia, in 2023. METHODS: An institutional-based cross-sectional study was conducted from March 2 to March 31, 2023, among 428 nurses working in 32 health centers in Addis Ababa, Ethiopia. Data were entered into Epi-Info version 7.2.5.0 and then exported to SPSS version 27 for analysis. Descriptive statistics (frequencies and proportions) were used to summarize the data on the study variables. Bivariate and multivariate logistic regression analyses were conducted to determine the strength of the association, and the statistical significance of associations between the variables was determined using adjusted odds ratio with a 95% CI and p values < 0.05. RESULTS: HBV-full vaccination coverage among 428 nurses in health centers in Addis Ababa, Ethiopia, was 36.9%. Male nurses [AOR = 1.78, 95% CI: 1.08, 2.95], taking training on infection prevention [AOR = 1.73, 95% CI: 1.08, 2.78], having good knowledge about HBV vaccine [AOR = 1.98, 95% CI: 1.28, 3.04], and testing for HBV [AOR = 1.98, 95% CI: 1.08, 3.64] were more likely to have HBV full vaccination coverage, whereas monthly salary ≤ 7,071 Ethiopian Birr was 54% less likely to have HBV full vaccination coverage [AOR = 0.46, 95% CI: 0.25, 0.85] at p-value < 0.05. CONCLUSION: This study revealed that the full HBV vaccination coverage of nurses working in health centers in Addis Ababa, Ethiopia, was low (36.9%), and consequently, the majority of nurses are at a high risk of being infected with HBV. Therefore, the Ministry of Health and health centers should promote awareness, implement prevention programs, provide diagnostic, treatment, and care services, enhance information generation and utilization, and strengthen the health system to increase vaccination coverage among nurses.

Enhancing Behavioral Health Implementation in a Care Coordination Program at a Federally Qualified Health Center: A Case Study Applying Implementation Frameworks.

Federally Qualified Health Centers are charged with providing comprehensive health care in traditionally underserved areas, underscoring their importance in caring for and promoting health equity for the large portion of historically marginalized communities in this setting. There is a significant need to ensure Federally Qualified Health Centers are equipped to appropriately address the immense behavioral health needs common among patients served. Care coordination is an evidence-based model that is increasingly utilized in Federally Qualified Health Centers to improve care equity and outcomes. Addressing and supporting behavioral health needs is a key aspect of such care coordination models. Context-specific considerations and programmatic supports, particularly those that address the needs of care coordinators and the complex patients they serve, are needed to ensure such models can appropriately meet and address the behavioral health concerns of the diverse populations served. The goal of this study was to present a mixed-methods case study that systematically applies implementation frameworks to conduct a needs and context assessment to inform the development and testing of evidence-based practice strategies and implementation support as part of a care coordination program within a partnered Federally Qualified Health Center.

The Importance of Patient Experience in Obtaining Mental Health Care at HRSA-Funded Health Centers.

Timely mental health care prevents more complex and costly psychological problems, particularly for underserved individuals utilizing HRSA-funded health centers. Patient experience with care services and provider interactions may facilitate timely mental health care access. This study explored which elements of patient experience at health centers minimize delayed access to necessary mental health care. We used cross-sectional data on adult patients who needed mental health services from the 2022 Health Center Patient Survey (N = 1039). Multi-variable logistic regression analyses examined the influence of patient experience using measures drawn from the Consumer Assessment of Healthcare Providers and Systems on delayed mental health care, accounting for predisposing, enabling, and need factors. 82% of patients did not cite delayed mental health care. 60% or more of patients reported always or usually receiving responsive and coordinated care, with over 80% reporting always or usually receiving positive provider interactions. Lower odds of delayed mental health care was associated with always getting timely callback during business hours (adjusted odds ratio [aOR]: 0.26; 95% confidence interval [CI]: 0.09, 0.76), and that the provider always listened carefully (aOR: 0.33; CI: 0.14, 0.78), provided easy to understand recommendations (aOR: 0.31, CI: 0.12, 0.79), knew the patient's medical history (aOR: 0.33, CI: 0.15, 0.73), was respectful to the patient (aOR: 0.49, CI: 0.27, 0.90), or was easy to understand (aOR: 0.51, CI: 0.29, 0.88). Care responsiveness and positive provider communication are integral to facilitating timely mental health care access for vulnerable populations with mental health needs.

[Relationship between the number of public health nurses and the total number of people receiving home-visit nursing services for mental health/intractable diseases, and those numbers' regional differences].

Objectives　The primary aim of this study was to clarify the relationship between the number of public health nurses (PHNs) and the total number of people who received home-visit nursing services for mental health or intractable diseases. The secondary aim was to clarify the extent of regional differences in the number of PNHs and mental health or intractable diseases.Methods　This study used the total number of people who received home-visit nursing services for mental health or intractable diseases in 2019 from the Portal Site of Official Statistics of Japan (e-Stat) and population and area data in January 2020. Single and multiple regression analyses (covariates: population and area) were performed on the relationship between the number of PHNs per 100,000 population (abbreviated as "ratios of PHNs") and the total number of people who received home-visit nursing services for mental health or intractable diseases per 100,000 population (abbreviated as "mental health/intractable disease achievements"). Regional differences in ratios of PHNs and mental health/intractable disease achievement were examined using mean, standard deviation, maximum/minimum values, and Gini coefficients. Analyses were performed for each of the five units: the prefectures as a whole, prefectural public health centers, municipalities within the jurisdiction of prefectural public health centers, and cities in which public health centers are established (including or not including special wards).Results　Regression analyses indicated a positive relationship between the ratios of PHNs and mental health/intractable disease achievements. Multiple regression analysis indicated that both achievements were positively associated with population size and negatively associated with area size. The largest regression coefficients between the ratios of PHNs and achievements were 34.07 and 5.48 regarding mental health achievements and intractable disease achievements, respectively. For regional differences, the smallest Gini coefficient was the ratios of PHNs, and the largest was intractable disease achievements. The smallest and largest coefficient of the prefectures as a whole was 0.15 and 0.34, respectively. The maximum/minimum values of the prefectures as a whole also indicated that the smallest was 3.8 in the ratio of PHNs and the largest was 30.0 in intractable disease achievement.Conclusions　Increasing number of PHNs is needed to provide more home-visit nursing services for mental health and intractable diseases. It is particularly important to fill up the larger number of PHNs in smaller populations or larger area prefectures. Due to regional differences in the home-visit nursing service, it is important to promote the increase in the level of these activities.

[Salt reduction attempts in workers after specific food service facility guidance provided by a public health center: A case study at a worksite in Kawagoe City, Saitama Prefecture].

Objective　The Kawagoe City Public Health Center implemented a project to reduce salt intake through specific food service facility guidance in workplace cafeterias. Here, we report the study results.Methods　The target worksite was company A, with approximately 270 employees, located in Kawagoe City, Saitama Prefecture. There were 214 participants (approximately 80%). The project was conducted from November 2019 to November 2021. The long-term goal was to decrease the number of hypertensive cases in the city. Project outcomes included decreased salt intake, urinary sodium/potassium ratio, and average blood pressure. The project aimed to improve the cafeteria menu, focusing on salt reduction by offering Smart Meals® and reducing the salt equivalents in all menus. The project output indicators included reduced amount of salt in cafeteria menu items, increased frequency of cafeteria use, increased positive evaluations of the cafeteria, and increased daily awareness of the need for salt reduction. Spot urine samples, blood pressure measurements, and self-administered questionnaire data were collected during annual physical examinations. The amount of salt in the cafeteria menu was evaluated by receiving monthly data from the food service company to which company A outsourced its cafeteria operations.Results　The analysis included 102 individuals with complete data from to 2019-2021. Estimated salt intake (g/day) from spot urine decreased from 10.3±2.1 in 2019 to 9.8±2.4 in 2020 and 9.5±2.0 in 2021 (P=0.003). Systolic blood pressure (mmHg) decreased from 114.7±12.5 in 2019 to 111.7±12.1 in 2020 and 110.6±12.0 in 2021 (P=0.010). Compared to 2019, changes in dietary salt equivalents in cafeteria menus in 2020 and 2021decreased for set meals A and B, curries, and noodles (P<0.001).Conclusion　We offered Smart Meals® and reduced salt equivalents in all workplace cafeteria menus. After 1-2 years, employees' salt intake and blood pressure levels were lower. These results provide implications for the implementation of food environment improvements in public health centers and other local government agencies to promote the Health Japan 21 (third term) strategy.

Pilot Study Focused on Knowledge, Attitudes, and Health Access Behaviors of Psychiatric-Mental Health Nurses Regarding Suicide Prevention.

OBJECTIVE: The purpose of this pilot study was to evaluate the effect of a web-based education module on the knowledge, attitudes, and ratings of willingness to access help related to suicide prevention in psychiatric-mental health nurses. METHODS: A quasi-experimental pretest-posttest design was employed. Registered nurses from two academic health center units and a 239-bed Psychiatric Hospital were invited to participate. Scores on knowledge of suicide risk and prevention, attitudes, subjective norms, perceived behavioral control, and intent to seek help upon experiencing suicidal ideations were obtained before and after administering a 25-min web-based training. RESULTS: Twenty-nine participants completed the pre-survey, web-based education module, and post-survey. Significant increases from baseline in the scores on knowledge, attitudes, subjective norms, and intentions related to help-seeking behaviors for nurse suicide prevention were noted. Perceived behavioral control median scores increased but were not statistically significant. More than 40% of the participants reported having experienced suicidal thoughts. CONCLUSIONS: Further study is needed to determine contributors to this higher rate. Understanding the effectiveness of strategies to reduce nurse suicide can provide insights into building better nurse suicide prevention programs.