A Pilot Test of Game Changers, a Social Network Intervention to Empower People with HIV to be Prevention Advocates in Uganda.

We conducted a pilot randomized controlled trial of Game Changers, a 6-session group intervention that empowers people with HIV to be HIV prevention advocates in their social networks. Ninety-nine people with HIV (51 intervention, 48 wait-list control) and 58 of their social network members (alters) completed baseline and 5- and 8-month post-baseline assessments. Results indicated high acceptability, demonstrated by participants' and facilitators' positive attitudes qualitatively and favorable ratings of intervention sessions quantitatively, and high feasibility (76% attended all intervention sessions). Intention-to-treat analyses indicated significantly increased HIV prevention advocacy among HIV-positive participants and alters [b (SE) = 0.4 (0.2), p = .017; b (SE) = 0.4 (0.2), p = .035]; reduced internalized HIV stigma [b (SE) = - 0.3 (0.1), p = .012], increased HIV-serostatus disclosure [b (SE) = 0.1 (0.1), p = .051], and increased social network density among HIV-positive participants [b (SE) = 0.1 (0.03), p = .004]; and marginally reduced condomless sex among alters [OR (95% CI) = 0.3 (0.1-1.2), p = .08]. Positioning people with HIV as central to prevention has the potential to reduce stigma and improve prevention outcomes throughout social networks.

Veterans Health Administration enrollees' choice of care setting relates to the expansion of care options: Evidence from screening colonoscopies before and after the MISSION Act.

OBJECTIVE: To estimate whether those enrolled in the Veterans Health Administration (VHA) were less likely to use VHA-delivered colorectal cancer screening colonoscopies after the MISSION Act. DATA SOURCES AND STUDY SETTING: Secondary data were collected on VHA-enrolled Veterans from FY2017-FY2021. STUDY DESIGN: This retrospective cross-sectional study measured the volume and share of screening colonoscopies that were VHA-delivered over time and by drive time eligibility-defined as living more than 60 min away from the nearest VHA specialty-care clinic. We used a multivariable logistic regression to adjust for patient and facility factors. DATA EXTRACTION: Data were extracted for VHA enrollees (n = 773,766) who underwent a screening colonoscopy either performed or purchased by the VHA from FY2017-FY2021. PRINCIPAL FINDINGS: In the 9 months after the implementation of the MISSION Act, and before the onset of the Covid-19 pandemic, the average monthly VHA-share of screening colonoscopies decreased by 3 percentage points (pp; 95% confidence interval [CI] = [-4 to -2 pp]) for the non-drive time eligible group and it decreased by 16 pp (95% CI = [-22 to -9 pp]) for the drive time eligible group. The total number of screening colonoscopies did not significantly change in either group during this time period. After adjusting for patient characteristics, a linear time trend, and parent facility fixed effects, implementation of the MISSION Act was associated with a reduction in the probability of a VHA-delivered screening colonoscopy (average marginal effect [AME]: -2.5 pp; 95% CI = [-5.1 to 0.0 pp]) for the non-drive time eligible group. The drive time eligible group (AME: -9.4 pp; 95% CI = [-13.2 to -5.5 pp]) experienced a larger change. CONCLUSIONS: The VHA-share of screening colonoscopies among VHA enrollees fell in the 9 months immediately after the passage of the MISSION Act. This decline was larger for VHA enrollees who were targeted for eligibility due to a longer drive time. These results suggest that the MISSION Act led to more VHA-purchased care among targeted VHA enrollees, though it is unclear whether total utilization increased.

Determinants of referral network size for screening colonoscopies in the Veterans Health Administration after the implementation of the MISSION Act.

OBJECTIVE: To measure key characteristics of the Veterans Health Administration's (VHA) Community Care (CC) referral network for screening colonoscopy and identify market and institutional factors associated with network size. DATA SOURCES: VHA electronic health records, CC claim data, and National Plan and Provider Enumeration System. STUDY DESIGN: In this retrospective cross-sectional study, we measure the size of the VHA's CC referral networks over time and by VHA parent facility (n = 137). We used a multivariable linear regression to identify factors associated with network size at the market-year level. Network size was measured as the number of physicians who performed at least one VHA-purchased screening colonoscopy per 1000 enrollees at baseline. DATA EXTRACTION: Data were extracted for all Veterans (n = 102,119) who underwent a screening colonoscopy purchased by the VHA from a non-VHA physician from 2018 to 2021. PRINCIPAL FINDINGS: From 2018 to 2021, median network volume of screening colonoscopies per 1000 enrollees grew from 1.6 (IQR: 0.6, 4.6) to 3.6 (IQR: 1.6, 6.6). The median network size grew from 0.63 (IQR: 0.30, 1.26) to 0.92 (IQR: 0.57, 1.63). Finally, the median procedures per physician increased from 2.5 (IQR: 1.6, 4.2) to 3.2 (IQR: 2.4, 4.7). After adjusting for baseline market characteristics, volume of screening colonoscopies was positively related to network size (ß = 0.15, 95% CI: [0.10, 0.20]), negatively related to procedures per physician (ß = -0.12, 95% CI: [-0.18, -0.05]), and positively associated with the percent of rural enrollees (ß = 0.01, 95% CI: [0.00, 0.01]). CONCLUSIONS: VHA facilities with a higher volume of VHA-purchased screening colonoscopies and more rural enrollees had more non-VHA physicians providing care. Geographic variation in referral networks may also explain differences in the effects of the MISSION Act on access to care and patient outcomes.

Advancing health equity through social care interventions.

OBJECTIVE: To use evidence on addressing racism in social care intervention research to create a framework for advancing health equity for all populations with marginalized social identities (e.g., race, gender, and sexual orientation). Such groups have disproportionate social needs (e.g., food insecurity) and negative social determinants of health (SDOH; e.g., poverty). We recommend how the Agency for Healthcare Research and Quality (AHRQ) could advance health equity for marginalized populations through social care research and care delivery. DATA SOURCES AND STUDY SETTING: This commentary is informed by a literature review of social care interventions that were affiliated with healthcare systems; input from health equity researchers, policymakers, and community leaders attending the AHRQ Health Equity Summit; and consensus of the authors. PRINCIPAL FINDINGS: We recommend that AHRQ: (1) create an ecosystem that values research on SDOH and the effectiveness and implementation of social care interventions in the healthcare sector; (2) work with other federal agencies to (a) develop position statements with actionable recommendations about racism and other systems that perpetuate marginalization based on social identity and (b) develop aligned, complementary approaches to research and care delivery that address social marginalization; (3) advance both inclusive care delivery and inclusive research teams; (4) advance understanding of racism as a social determinant of health and effective strategies to mitigate its adverse impact on health; (5) advance the creation and scaling of effective strategies for addressing SDOH in healthcare systems, particularly in co-creation with community partners; and (6) require social care intervention researchers to use methods that advance our understanding of social health equity. CONCLUSIONS: AHRQ, as a federal agency, could help advance health equity using a range of strategies, including using the agency's levers to ensure AHRQ stakeholders examine and address the unique experiences of socially marginalized populations in SDOH and social care intervention research.

Participation in a Medicare advanced primary care model and the delivery of high-value services.

OBJECTIVE: To evaluate whether primary care providers' participation in the Comprehensive Primary Care Plus Initiative (CPC+) was associated with changes in their delivery of high-value services. DATA SOURCES: Medicare Physician & Other Practitioners public use files from 2013 to 2019, 2017 to 2019 Medicare Part B claims for a 5% random sample of Medicare Fee-for-Service (FFS) beneficiaries, the Area Health Resources File, the National Plan & Provider Enumeration System files, and public use datasets from the Centers for Medicare & Medicaid Services Physician Compare. STUDY DESIGN: We used a difference-in-difference approach with a propensity score-matched comparison group to estimate the association of CPC+ participation with the delivery of annual wellness visits (AWVs), advance care planning (ACP), flu shots, counseling to prevent tobacco use, and depression screening. These services are prominent examples of high-value services, providing benefits to patients at a reasonable cost. We examined both the likelihood of delivering these services within a year and the count of services delivered per 1000 Medicare FFS beneficiaries per year. DATA COLLECTION/EXTRACTION METHODS: Secondary data are linked at the provider level. PRINCIPAL FINDINGS: We find that CPC+ participation was associated with increases in the likelihood of delivering AWVs (13.03 percentage points by CPC+'s third year, p < 0.001) and the number of AWVs per 1000 Medicare FFS beneficiaries (44 more AWVs by CPC+'s third year, p < 0.001). We also find that CPC+ participation was associated with more flu shots per 1000 beneficiaries (52 more shots by CPC+'s third year, p < 0.001) but not with the likelihood of delivering flu shots. We did not find consistent evidence for the association between CPC+ participation and ACP services, counseling to prevent tobacco use, or depression screening. CONCLUSIONS: CPC+ participation was associated with increases in the delivery of AWVs and flu shots, but not other high-value services.

Identifying violence against persons at a safety-net hospital: Evidence from the first 6 months of implementation.

OBJECTIVE: To examine the prevalence and predictors of screening for violence against persons and victim service utilization within an integrated safety-net health system. STUDY SETTING: Emergency Department (ED) at Parkland Hospital-Dallas County's largest safety-net provider of services for minority and underinsured and uninsured patients. STUDY DESIGN: Prospective, longitudinal study during the first 6 months of a universal violence against persons screener. DATA COLLECTION: Health records were extracted for all patients with a visit to the ED between January and July, 2021. Modeling described the patient population across screening (screened vs. not screened) and, among those screened, the results (positive vs. negative), average time spent in the ED, and referral patterns for victim services. PRINCIPAL FINDINGS: During the study period, 65,563 unique patients with 95,555 encounters occurred. Seventy-one percent (n = 67,535) were screened for violence against persons and, of those, 2% screened positive (n = 1349). Of the patients who screened positive, 1178 (87%) were referred to and 806 (60%) received care at victim services. Implementing screening did not increase the length of stay at ED. CONCLUSIONS: Systematic implementation of comprehensive violence screening at a safety-net system can result in robust identification and timely referrals to victim services.

Estimating the Cost of Providing Foundational Public Health Services.

OBJECTIVE: To estimate the cost of resources required to implement a set of Foundational Public Health Services (FPHS) as recommended by the Institute of Medicine. STUDY DESIGN: A stochastic simulation model was used to generate probability distributions of input and output costs across 11 FPHS domains. We used an implementation attainment scale to estimate costs of fully implementing FPHS. DATA COLLECTION/EXTRACTION METHODS: We use data collected from a diverse cohort of 19 public health agencies located in three states that implemented the FPHS cost estimation methodology in their agencies during 2014-2015. PRINCIPAL FINDINGS: The average agency incurred costs of $48 per capita implementing FPHS at their current attainment levels with a coefficient of variation (CV) of 16 percent. Achieving full FPHS implementation would require $82 per capita (CV=19 percent), indicating an estimated resource gap of $34 per capita. CONCLUSIONS: Substantial variation in costs exists across communities in resources currently devoted to implementing FPHS, with even larger variation in resources needed for full attainment. Reducing geographic inequities in FPHS may require novel financing mechanisms and delivery models that allow health agencies to have robust roles within the health system and realize a minimum package of public health services for the nation.

Promoting healthy eating in primary health care from the perspective of health professionals: a qualitative comparative study in the context of South America.

BACKGROUND: Educational interventions designed to promote healthy eating are essential in primary health care. Nevertheless, given the nutrition controversies about what is healthy, the contradictions created by the media, and the situation of users with complex needs, the prioritization of the themes to be addressed in the services has scarcely been described in the planning process. This study aimed to identify the process of implementing the themes discussed by health professionals in nutrition education groups in two primary health care models. METHODS: Our study followed a qualitative comparative approach. It included the systematic observation of nutrition education group meetings to identify the key messages addressed and semi-structured interviews with health professionals in São Paulo, Brazil, and in Bogotá, Colombia. We used thematic networks to classify the messages and the collective subject discourse technique to organize the information obtained from interviews. We observed 28 nutrition education groups in São Paulo, and 13 in Bogotá, and conducted 27 interviews with nutritionists in each city. RESULTS: The messages identified were grouped into four global themes: feeding habits, life cycle, disease, and "being a multiplier". The process of implementing the themes, understood as identification, selection, consultation, and application of themes, is intermediated by social representations of the health professionals about service requirements, training and professional performance, and the relationship with users. Two notions shape these representations: Control, although the time and the physical space dedicated to health services are restricted to the disease in São Paulo, in Bogotá only limited health promotion is provided; and specificity, which is portrayed as therapeutic support within a more educational model in São Paulo and as health promotion training courses within a prescriptive model in Bogotá. CONCLUSIONS: Understanding the process of implementing the themes discussed in nutrition education groups can reveal mechanisms that support the approach to themes on healthy eating, including communicative and educational adaptations of health professionals. This study contributes to the discussion about educational models in health care and their effects on the qualifications of health professionals within the service, especially those included in the context of low- and middle-income settings.

Patient Acceptance of Sexual Orientation and Gender Identity Questions on Intake Forms in Outpatient Clinics: A Pragmatic Randomized Multisite Trial.

OBJECTIVES: To (1) test whether patient attitudes toward intake forms at three Midwestern outpatient clinics are significantly more negative among those who are asked to complete SOGI questions versus those who are not; and (2) gain an in-depth understanding of patient concerns about SOGI questions. STUDY SETTING: Data were collected between 6/29/2015 and 2/29/2016 from new patients (N = 491) who presented at three outpatient clinics in a large academic medical center. This study was originally a quality improvement project, and later, institutional review board approval was obtained for secondary data analysis. STUDY DESIGN: Two-stage mixed-methods study. (1) Experimental: New patients at three sites were randomly assigned to complete either routine intake forms (control) or routine intake forms with SOGI questions (experimental); and (2) qualitative: interviews with patients who responded negatively to SOGI questions. PRINCIPAL FINDINGS: There were no significant differences in patient attitudes between experimental and control groups (p > .05). Of those who received SOGI questions, only 3 percent reported being distressed, upset, or offended by the SOGI questions. CONCLUSIONS: Collection of SOGI data as a part of the routine clinical patient intake process is not distressing to 97 percent of patients who are heterosexual, cisgender, and older than 50 years.

Diseño y validación técnica del ícono del Plato Nutricional para la alimentación diaria de los guatemaltecos / Design and validation of a Healthy Plate´s model for Guatemalans daily food

Por varias décadas en el país, se han utilizado las Guías Alimentarias para Guatemala, en diferentes programas de salud, educación o seguridad alimentaria nutricional con el fin de orientar una alimentación saludable a la población logrando incidir con cierto éxito y eficacia; sin embargo, existen algunas limitaciones de comprensión y aplicación. En el contexto y objetivos de este recurso educativo, se consideró elaborar un modelo del Plato Nutricional para la población guatemalteca como una herramienta que permita orientar el consumo de una alimentación balanceada en las diferentes comidas del día e impactar en cambios de comportamiento positivos en la alimentación de las poblaciones más vulnerables del país. Se revisó literatura sobre el diseño de materiales, normativas de educación y situación de los problemas alimentarionutricionales de la población guatemalteca, se diseñó el modelo y un panel de 12 expertos valoró los criterios de aceptación, comprensión e inducción a la acción. Sobre el ícono o gráfico del plato nutricional, se calificaron aspectos de percepción sobre la alimentación balanceada y la proporcionalidad de los grupos de alimentos a comer en forma diaria en los distintos tiempos de comida. Entre los principales resultados están que el modelo del Plato Nutricional promueve una alimentación saludable, los 12 expertos (100.0% de los participantes en la validación técnica) refirieron que la metodología es de utilidad, y 10 (83.3%) indicaron que todos los materiales cumplieron con los criterios de atracción, comprensión, congruencia, aceptación e inducción a la acción. El modelo del plato considerado como un gráfico simple pero óptimo para orientar la alimentación adecuada para los guatemaltecos, es una herramienta educativa complementaria a las Guías Alimentarias para Guatemala

For several decades, the Dietary Guidelines for Guatemala have been used in different health, education, or nutritional food security programs in order to guide the population to a healthy diet, managing to influence with certain success and effectiveness. However, there are some understanding and application limitations. In the context and objectives of this educational resource, the development of a model of the Nutritional Plate was considered for the Guatemalan population, as a tool that allows guiding the consumption of a balanced diet in the different meals of the day, and promoting positive changes in eating behavior in the most vulnerable populations of the country. Literature on the design of materials, educational regulations, and the situation of food-nutritional problems of the Guatemalan population were reviewed, the model was designed, and a panel of 12 experts assessed the criteria for acceptance, understanding, and induction to action. Regarding the Healthy Plate´s model, aspects such as perception of a balanced diet and the proportionality of the food groups of the different daily meals, were rated. Among the main results are that the Nutritional Plate model promotes healthy eating, the 12 experts (100.0% of the participants in the technical validation) reported that the methodology is useful, and 10 (83.3%) indicated that all the materials complied with the criteria of attraction, understanding, congruence, acceptance, and induction to action. The healthy plate model, considered a simple but optimal graphic to guide the adequate diet for Guatemalans, is an educational tool complementary to the Dietary Guidelines for Guatemala.

Diseño y validación técnica del ícono del Plato Nutricional para la alimentación diaria de los guatemaltecos / Design and validation of a Healthy Plate´s model for Guatemalans daily food

Por varias décadas en el país, se han utilizado las Guías Alimentarias para Guatemala, en diferentes programas de salud, educación o seguridad alimentaria nutricional con el fin de orientar una alimentación saludable a la población logrando incidir con cierto éxito y eficacia; sin embargo, existen algunas limitaciones de comprensión y aplicación. En el contexto y objetivos de este recurso educativo, se consideró elaborar un modelo del Plato Nutricional para la población guatemalteca como una herramienta que permita orientar el consumo de una alimentación balanceada en las diferentes comidas del día e impactar en cambios de comportamiento positivos en la alimentación de las poblaciones más vulnerables del país. Se revisó literatura sobre el diseño de materiales, normativas de educación y situación de los problemas alimentario-nutricionales de la población guatemalteca, se diseñó el modelo y un panel de 12 expertos valoró los criterios de aceptación, comprensión e inducción a la acción. Sobre el ícono o gráfico del plato nutricional, se calificaron aspectos de percepción sobre la alimentación balanceada y la proporcionalidad de los grupos de alimentos a comer en forma diaria en los distintos tiempos de comida. Entre los principales resultados están que el modelo del Plato Nutricional promueve una alimentación saludable, los 12 expertos (100.0% de los participantes en la validación técnica) refirieron que la metodología es de utilidad, y 10 (83.3%) indicaron que todos los materiales cumplieron con los criterios de atracción, comprensión, congruencia, aceptación e inducción a la acción. El modelo del plato considerado como un gráfico simple pero óptimo para orientar la alimentación adecuada para los guatemaltecos, es una herramienta educativa complementaria a las Guías Alimentarias para Guatemala.

For several decades, the Dietary Guidelines for Guatemala have been used in different health, education, or nutritional food security programs in order to guide the population to a healthy diet, managing to influence with certain success and effectiveness. However, there are some understanding and application limitations. In the context and objectives of this educational resource, the development of a model of the Nutritional Plate was considered for the Guatemalan population, as a tool that allows guiding the consumption of a balanced diet in the different meals of the day, and promoting positive changes in eating behavior in the most vulnerable populations of the country. Literature on the design of materials, educational regulations, and the situation of food-nutritional problems of the Guatemalan population were reviewed, the model was designed, and a panel of 12 experts assessed the criteria for acceptance, understanding, and induction to action. Regarding the Healthy Plate´s model, aspects such as perception of a balanced diet and the proportionality of the food groups of the different daily meals, were rated. Among the main results are that the Nutritional Plate model promotes healthy eating, the 12 experts (100.0% of the participants in the technical validation) reported that the methodology is useful, and 10 (83.3%) indicated that all the materials complied with the criteria of attraction, understanding, congruence, acceptance, and induction to action. The healthy plate model, considered a simple but optimal graphic to guide the adequate diet for Guatemalans, is an educational tool complementary to the Dietary Guidelines for Guatemala.

Workforce Characteristics and Attitudes Regarding Participation in Worksite Wellness Programs.

PURPOSE: To estimate workforce participation characteristics and employees' attitudes regarding participation in workplace wellness programs. DESIGN: Data from a statewide stratified random sample were used to compare small (<50 employees) and larger (50+ employees) workplaces to estimate participation in screening programs and likelihood of participation in workplace wellness programs. SETTING: A telephone survey of employed Iowans registered to vote. SUBJECTS: Surveyed were 1171 employed Iowans registered to vote, ages 18 to 65. MEASURE: Among questionnaire survey modules were items from the Wellness Council of America Employee Needs and Interest Survey, the U.S. Census Bureau for employment documentation, and the World Health Organization Health and Work Performance Questionnaire for assessment of sickness absenteeism and presenteeism. ANALYSIS: Prevalence of participation in screening and wellness programs was analyzed by employment size and levels of likeliness to participate, and multivariable analyses of employee baseline characteristics regarding participation in screening programs and likelihood of participation in wellness programs was presented as top and bottom quartiles. RESULTS: Those employed in smaller workplaces participated less often in screening programs. Multivariable models identified male gender and those with an abnormal body mass index were associated with nonparticipation, while having a primary care physician was associated with participation. Very few items showed significant statistical difference in willingness to participate. CONCLUSION: Workforce characteristics and access to health care may influence participation in screening and wellness programs. Employment size is not a determining factor for willingness to participate in wellness programs.