Associations among enacted weight stigma, weight self-stigma, and multiple physical health outcomes, healthcare utilization, and selected health behaviors.

BACKGROUND: This study examined the relationship among enacted weight stigma, weight self-stigma, and multiple health outcomes. Weight stigma, a stressor experienced across all body sizes, may contribute to poorer physical health outcomes by activating the nervous and endocrine system or by triggering counterproductive health behaviors like lower physical activity, maladaptive eating patterns, and delayed health care, as well as provider bias that may cause a medical concern to be discounted. While associations of weight stigma with mental health issues are well documented, less is known about its association with physical health. METHODS: We enrolled 3821 adults who completed an online survey assessing enacted weight stigma, weight self-stigma, multiple self-reported physical health outcomes, healthcare utilization, and selected health behaviors. RESULTS: After controlling for BMI, health care delay or avoidance, sedentary behavior, and selected demographic characteristics, enacted weight stigma, significantly increased the odds of six physical health problems including hypertension (OR 1.36; CI 1.08, 1.72), hyperglycemia (OR 1.73; CI 1.29, 2.31), thyroid disorder, (OR 1.65; CI 1.27, 2.13), any arthritis (OR 1.70; CI 1.27, 2.26), non-arthritic chronic pain (OR 1.76; CI 1.4, 2.29), and infertility (OR 1.53; CI 1.14, 2.05). Weight self-stigma significantly increased the odds for three physical health problems including hypertension (OR 1.43; CI 1.16, 1.76), hyperglycemia (OR 1.37; CI 1.03, 1.81), and non-arthritic chronic pain (OR 1.5; CI 1.2,1.87). Enacted stigma was associated with more than a four-fold increase in odds of believing that a medical concern was disregarded by a health care provider. CONCLUSIONS: In this study, enacted stigma and weight self-stigma were independently associated with heightened risk for multiple physical health problems, as well as, believing health concerns were discounted by providers. Reducing weight stigma may be an important component of managing multiple physical health conditions.

Veteran-Reported Receipt of Prepregnancy Care: Data from the Examining Contraceptive Use and Unmet Need (ECUUN) Study.

OBJECTIVES: To identify the prevalence of women Veterans reporting receipt of counseling about health optimization prior to pregnancy, topics most frequently discussed, and factors associated with receipt of this care. METHODS: We analyzed data from a nationally representative, cross-sectional telephone survey of women Veterans (n = 2302) ages 18-45 who used VA for primary care in the previous year. Our sample included women who were (1) currently pregnant or trying to become pregnant, (2) not currently trying but planning for pregnancy in the future, or (3) unsure of pregnancy intention. Multivariable logistic regression was used to examine adjusted associations of patient- and provider-level factors with receipt of any counseling about health optimization prior to pregnancy (prepregnancy counseling) and with counseling on specific topics. RESULTS: Among 512 women who were considering or unsure about pregnancy, fewer than half (49%) reported receiving any prepregnancy counseling from a VA provider in the past year. For those who did, the most frequently discussed topics included healthy weight (29%), medication safety (27%), smoking (27%), and folic acid use before pregnancy (27%). Factors positively associated with receipt of prepregnancy counseling include history of mental health conditions (aOR = 1.96, 95% CI: 1.28, 3.00) and receipt of primary care within a dedicated women's health clinic (aOR = 2.07, 95% CI: 1.35, 3.18), whereas factors negatively associated include far-future and unsure pregnancy intentions (aOR = 0.35, 95% CI: 0.17, 0.71 and aOR = 0.33, 95% CI: 0.16, 0.70, respectively). CONCLUSIONS FOR PRACTICE: Routine assessment of pregnancy preferences in primary care could identify individuals to whom counseling about health optimization prior to pregnancy can be offered to promote patient-centered family planning care.

Characteristics of older adults using patient web portals to view their DXA results.

BACKGROUND: Sharing test results with patients via patient web portals is a new trend in healthcare. No research has been done examining patient web portal use with bone density test results. The objective of our study was to identify patient characteristics associated with the use of patient web portals to view their bone density test results. METHODS: A secondary analysis of data from a pragmatic randomized controlled trial of 7749 participants ≥50 years old that had presented for a dual energy X-ray absorptiometry (DXA) bone density test. Patients were interviewed at enrollment and 12 weeks later. Multivariable logistic regression identified patient characteristics that differentiated those who used the web portal from those who did not. RESULTS: Our sample included 4669 patients at the two (University of Iowa [UI], and Kaiser Permanente of Georgia [KPGA]) clinical sites that had patient web portals. Of these patients, 3399 (72.8%) reported knowing their test results 12 weeks post-DXA, with 649 (13.9%) reporting that they viewed their DXA results using the web portal. Web portal users were more likely to be from UI than KPGA, and were younger, more educated, had higher health literacy, had osteopenia, and had the same sex as their referring physician (all p < 0.05). CONCLUSION: Only 19.1% of the 3399 patients who knew their DXA results used the available patient web portals to find out about them. Web portal users differed from non-users on several characteristics. This suggests that simply making patient web portals available for use may not be sufficient to appreciably enhance patient awareness of their test results. Based on these findings, a better understanding of the reasons why older, less educated, and less activated patients do not access their test results through patient web portals is needed.

Racial Differences and Disparities in Osteoporosis-related Bone Health: Results From the PAADRN Randomized Controlled Trial.

BACKGROUND: Determining whether observed differences in health care can be called disparities requires persistence of differences after adjustment for relevant patient, provider, and health system factors. We examined whether providing dual-energy x-ray absorptiometry (DXA) test results directly to patients might reduce or eliminate racial differences in osteoporosis-related health care. DESIGN, SUBJECTS, AND MEASURES: We analyzed data from 3484 white and 1041 black women who underwent DXA testing at 2 health systems participating in the Patient Activation after DXA Result Notification (PAADRN) pragmatic clinical trial (ClinicalTrials.gov NCT-01507662) between February 2012 and August 2014. We examined 7 outcomes related to bone health at 12 weeks and 52 weeks post-DXA: (1) whether the patient correctly identified their DXA baseline results; (2) whether the patient was on guideline-concordant osteoporosis pharmacotherapy; (3) osteoporosis-related satisfaction; (4) osteoporosis knowledge; (5 and 6) osteoporosis self-efficacy for exercise and for diet; and (7) patient activation. We examined whether unadjusted differences in outcomes between whites and blacks persisted after adjusting for patient, provider, and health system factors. RESULTS: Mean age was 66.5 years and 29% were black. At baseline black women had less education, poorer health status, and were less likely to report a history of osteoporosis (P<0.001 for all). In unadjusted analyses black women were less likely to correctly identify their actual DXA results, more likely to be on guideline-concordant therapy, and had similar patient activation. After adjustment for patient demographics, baseline health status and other factors, black women were still less likely to know their actual DXA result and less likely to be on guideline-concordant therapy, but black women had greater patient activation. CONCLUSIONS: Adjustment for patient and provider level factors can change how racial differences are viewed, unmasking new disparities, and providing explanations for others.

Activating Patients With a Tailored Bone Density Test Results Letter and Educational Brochure: the PAADRN Randomized Controlled Trial.

In cross-sectional studies, patient activation has been associated with better health behaviors, health outcomes, and health-care experiences. Moreover, tailored interventions have led to clinically meaningful improvements in patient activation, as well as health outcomes over time. We tested whether a tailored patient-activation letter communicating bone mineral density (BMD) test results plus an educational brochure improved patient activation scores and levels at 12 and 52 wk post-baseline as the mechanism leading to enhanced bone healthcare. In a randomized, controlled, double-blinded, multicenter pragmatic clinical trial, we randomized 7749 patients ≥50 yr old and presenting for BMD testing at 3 medical centers in the United States between February 2012 and August 2014. The outcome measures were patient activation scores and levels based on 6 items taken from the Patient Activation Measure (PAM) that were administered at the baseline, 12-wk, and 52-wk follow-up interviews. Mean age was 66.6 yr, 83.8% were women, and 75.3% were Non-Hispanic-Whites. Overall, PAM activation scores improved from 58.1 at baseline to 76.4 by 12 wk (p < 0.001) and to 77.2 (p = 0.002) by 52 wk post-baseline. These improvements, however, were not significantly different between the intervention and usual care groups (18.7 vs 18.1, p = 0.176, at 12 wk) in intention-to-treat analyses. PAM activation scores and levels substantially improved at 12 wk and 52 wk, but no differences were observed in these improvements between the intervention and usual care groups. These null findings may have occurred because the tailoring focused on the patient's BMD and fracture risk results, rather than on the patient's BMD and fracture risk results as well as the patient's baseline PAM activation scores or levels.

Patient-reported reasons for nonadherence to recommended osteoporosis pharmacotherapy.

OBJECTIVES: As many as one-half of patients recommended for osteoporosis pharmacotherapy do not take their medications. To identify intervention targets, we examined patient characteristics associated with nonadherence to recommended pharmacotherapy and their reasons for nonadherence. METHODS: Data come from the Patient Activation after DXA Result Notification (PAADRN) study, a randomized controlled trial of 7749 patients aged 50 years or older presenting for dual-energy X-ray absorptiometry (DXA) at 3 health centers in the United States. We focused on the 790 patients who reported receiving a recommendation for new pharmacotherapy at baseline. Using Pearson chi-squared tests for categorical variables, 2-sample t tests for continuous variables, and multivariable multinomial logistic regression, we compared those who reported starting the recommended medication (adherers) with temporary nonadherers and nonadherers on demographics, health habits, DXA impression, 10-year probability of fracture using the assessment tool, and osteoporosis knowledge, and we examined their stated reasons for nonadherence. RESULTS: Mean age was 66.8 years (SD = 8.9); 87.2% were women, and 84.2% were white. One-fourth of patients (24.8%) reported that they did not start their recommended pharmacotherapy. In the unadjusted analyses, the only factor significantly associated with nonadherence was osteoporosis knowledge, with those having better knowledge being less likely to take their medications (P < 0.05). The most common reasons for nonadherence were fear of adverse effects (53.3%), a dislike of taking medicine (25.3%), and the belief that the medication would not help their condition (16.7%). CONCLUSION: One in 4 patients recommended for osteoporosis pharmacotherapy declined treatment because they feared potential adverse effects, did not like taking medicine, or believed that the medication would not help their condition. Improved patient counseling on the potential adverse effects of osteoporosis treatment and the risk-benefit ratio for these medications may increase adherence.

Understanding Clinic Practices for Human Papilloma Virus Vaccination Series Completion in Clinics That Provide Primary Care: Survey of Clinic Managers in Iowa.

BACKGROUND: Rates for human papilloma virus (HPV) vaccination are low across the United States. Evidence-based-practices to increase immunization coverage have been recommended by public health organizations, yet many primary care clinics do not follow these practices. The purpose of this study was to examine if primary care clinics use these best practices to promote completion of the HPV vaccine series for their adolescent patients. Understanding the prevalence of evidence-based immunization strategies is key to increasing vaccination coverage. METHODS: We mailed 914 surveys to clinic managers of clinics that provide primary care in Iowa. The survey content was based on immunization strategies related to clinic practice and policies that have been proven effective to promote the completion of the HPV vaccination series. RESULTS: Survey responses from 127 clinics were used in the final analysis. Most clinics always used the state's immunization information system to record HPV vaccinations (89.4%). Over a quarter of clinics (27.6%) did not use any type of reminder or recall system to alert parents or providers that an HPV vaccine was due, and 35.0% did not give the vaccine at sick visits. CONCLUSIONS: Clinics need to focus more on the recommended logistics and processes to ensure that patients receive the entire HPV vaccination series. Survey results indicate that clinics are not consistently implementing the recommended best practices to ensure that vaccination series are completed.

Effects of a DXA result letter on satisfaction, quality of life, and osteoporosis knowledge: a randomized controlled trial.

BACKGROUND: Undiagnosed, or diagnosed and untreated osteoporosis (OP) increases the likelihood that falls result in hip fractures, decreased quality of life (QOL), and significant medical expenditures among older adults. We tested whether a tailored dual energy x-ray absorptiometry (DXA) test result letter and an accompanying educational bone-health brochure affected patient satisfaction, QOL, or OP knowledge. METHODS: The Patient Activation after DXA Result Notification (PAADRN) study was a double-blinded, pragmatic, randomized trial which enrolled patients from 2012 to 2014. We randomized 7,749 patients presenting for DXA at three health care institutions in the United States who were ≥ 50 years old and able to understand English. Intervention patients received a tailored letter four weeks after DXA containing their results, 10-year fracture risk, and a bone-health educational brochure. Control patients received the results of their DXA per the usual practices of their providers and institutions. Satisfaction with bone health care, QOL, and OP knowledge were assessed at baseline and 12- and 52-weeks after DXA. Intention-to-treat analyses used multiple imputation for missing data and random effects regression models to adjust for clustering within providers and covariates. RESULTS: At 12-weeks 6,728 (86.8 %) and at 52-weeks 6,103 participants (78.8 %) completed their follow-up interviews. The intervention group was more satisfied with their bone health care compared to the usual care group at both their 12- and 52-week follow-ups (standardized effect size = 0.28 at 12-weeks and 0.17 at 52-weeks, p < 0.001). There were no differences between the intervention and usual care groups in QOL or OP knowledge at either time point. CONCLUSIONS: A tailored DXA result letter and bone-health educational brochure sent to patients improved patient satisfaction with bone-related health care. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT01507662 First received: December 8, 2011.

Improving bone mineral density reporting to patients with an illustration of personal fracture risk.

BACKGROUND: To determine patients' preferences for, and understanding of, FRAX® fracture risk conveyed through illustrations. METHODS: Drawing on examples from published studies, four illustrations of fracture risk were designed and tested for patient preference, ease of understanding, and perceived risk. We enrolled a convenience sample of adults aged 50 and older at two medical clinics located in the Midwestern and Southern United States. In-person structured interviews were conducted to elicit patient ranking of preference, ease of understanding, and perceived risk for each illustration. RESULTS: Most subjects (n = 142) were female (64%), Caucasian (76%) and college educated (78%). Of the four risk depictions, a plurality of participants (37%) listed a bar graph as most preferred. Subjects felt this illustration used the stoplight color system to display risk levels well and was the most "clear," "clean," and "easy to read". The majority of subjects (52%) rated the pictogram as the most difficult to understand as this format does not allow people to quickly ascertain their individual risk category. CONCLUSIONS: Communicating risk to patients with illustrations can be done effectively with clearly designed illustrations responsive to patient preference. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01507662.

Implementation of Peer Messengers to Deliver Feedback: An Observational Study to Promote Professionalism in Nursing.

BACKGROUND: The Co-Worker Observation System (CORS) is a tool and a process to address disrespectful behavior through feedback from trained peer messengers. First used by physicians and advanced practice providers (APPs), CORS has been shown to decrease instances of unprofessional behaviors among physicians and APPs. The research team assessed the feasibility and fidelity of implementing CORS for staff nurses. METHODS: CORS was implemented at three academic medical centers using a project bundle with 10 essential implementation elements. Reports of unprofessional behavior among staff nurses that were submitted through the institution's electronic reporting system were screened through natural language processing software, coded by trained CORS coders using the Martinez taxonomy, and referred to a trained peer messenger to share the observations with the nurse. A mixed methods, observational design assessed feasibility and fidelity. RESULTS: A total of 590 reports from three sites were identified by the Center for Patient and Professional Advocacy from September 1, 2019, through August 31, 2021. Most reports included more than one problematic behavior, each of which was coded. Of the peer messages, 76.5% were successfully documented using the debriefing survey as complete, 2.2% as awaiting messenger feedback, and 0.2% as awaiting messenger assignments (total of 78.9 % considered delivered). A total of 21.1% were not shared; 4.7% of reports were intentionally not shared because the issue stemmed from a new system or policy implementation (4.0%) or because of known factors affecting the nurse (0.7%). CONCLUSION: CORS can be implemented with staff nurses efficiently when nursing infrastructure is adequate.

Iowa Implementation for Sustainability Framework.

BACKGROUND: An application-oriented implementation framework designed for clinicians and based on the Diffusion of Innovations theory included 81 implementation strategies with suggested timing for use within four implementation phases. The purpose of this research was to evaluate and strengthen the framework for clinician use and propose its usefulness in implementation research. METHODS: A multi-step, iterative approach guided framework revisions. Individuals requesting the use of the framework over the previous 7 years were sent an electronic questionnaire. Evaluation captured framework usability, generalizability, accuracy, and implementation phases for each strategy. Next, nurse leaders who use the framework pile sorted strategies for cultural domain analysis. Last, a panel of five EBP/implementation experts used these data and built consensus to strengthen the framework. RESULTS: Participants (n = 127/1578; 8% response) were predominately nurses (94%), highly educated (94% Master's or higher), and from across healthcare (52% hospital/system, 31% academia, and 7% community) in the USA (84%). Most (96%) reported at least some experience using the framework and 88% would use the framework again. A 4-point scale (1 = not/disagree to 4 = very/agree) was used. The framework was deemed useful (92%, rating 3-4), easy to use (72%), intuitive (67%), generalizable (100%), flexible and adaptive (100%), with accurate phases (96%), and accurate targets (100%). Participants (n = 51) identified implementation strategy timing within four phases (Cochran's Q); 54 of 81 strategies (66.7%, p < 0.05) were significantly linked to a specific phase; of these, 30 (55.6%) matched the original framework. Next, nurse leaders (n = 23) completed a pile sorting activity. Anthropac software was used to analyze the data and visualize it as a domain map and hierarchical clusters with 10 domains. Lastly, experts used these data and implementation science to refine and specify each of the 75 strategies, identifying phase, domain, actors, and function. Strategy usability, timing, and groupings were used to refine the framework. CONCLUSION: The Iowa Implementation for Sustainability Framework offers a typology to guide implementation for evidence-based healthcare. This study specifies 75 implementation strategies within four phases and 10 domains and begins to validate the framework. Standard use of strategy names is foundational to compare and understand when implementation strategies are effective, in what dose, for which topics, by whom, and in what context.

Associations Between Sexual Assault and Reproductive and Family Planning Behaviors and Outcomes in Female Veterans.

OBJECTIVE: To examine the relationship between lifetime sexual assault (defined as someone having experienced sexual assault in their lifetime) and reproductive health care seeking, contraception usage, and family planning outcomes in female veterans. METHODS: We conducted a secondary analysis of data collected between 2005 and 2008 from computer-assisted telephone interviews with 1,004 female veterans aged 20-52 years who were enrolled at two Midwestern Department of Veterans Affairs (VA) health care systems. Participants were asked about reproductive, mental, and general health histories, and about lifetime sexual assault. We assessed associations between reproductive histories and contraceptive use among participants who reported lifetime sexual assault, compared with those who had not experienced lifetime sexual assault, by using bivariate and multivariable logistic regression analyses. Lastly, we examined reasons why these participants had not sought Pap test screening. RESULTS: More than half (62%) of participants reported experiencing lifetime sexual assault. Because there was an association between older age and history of lifetime sexual assault (P<.001), we stratified the analysis by age. Women with a history of lifetime sexual assault were more likely to have had unprotected intercourse for a year or more (adjusted odds ratio [aOR] 2.31, 95% CI 1.35-3.96) and a teen pregnancy (aOR 2.10, 95% CI 1.07-4.12) than women who did not report lifetime sexual assault. When stratified by age, women aged 40-52 years with a history of lifetime sexual assault were more likely to report more than a year of unprotected sex, teen pregnancy, and not seeking prenatal care with their first pregnancy, than women aged 40-52 who did not report lifetime sexual assault. Women who experienced lifetime sexual assault were more likely to report not seeking Pap tests in the past owing to fear and anxiety when compared with women who had not experienced lifetime sexual assault. CONCLUSION: Female veterans who reported lifetime sexual assault had differences in family planning behaviors compared with women who did not report lifetime sexual assault. These findings have implications for clinicians and VA policymakers when determining family planning and reproductive care delivery needs for female veterans of reproductive age.

The Contribution of Patient, Primary Care Physician, and Primary Care Clinic Factors to Good Bone Health Care.

BACKGROUND/OBJECTIVE: Patient, provider, and system factors can contribute to chronic care management and outcomes. Few studies have examined these multilevel associations with osteoporosis care and outcomes. We examined how key process and structural factors at the patient, primary care physician (PCP), and primary care clinic (PCC) levels were associated with guideline concordant osteoporosis pharmacotherapy, daily calcium intake, vitamin D supplementation, and weekly exercise sessions at 52 weeks following enrollment in a cluster randomized controlled trial. METHODS: We conducted a secondary analysis of observational data from 1 site of the trial. The study sample included 1996 men and women ≥ 50 years of age at the time of recruitment following completion of a dual-energy x-ray absorptiometry (DXA) scan and who had complete data at baseline and 52 weeks. Our primary independent variable was "relationship continuity": the DXA-ordering provider was the patient's PCP. Hierarchical linear and logistic regression accounted for patient, provider, and primary care clinic characteristics. RESULTS: In multivariable regression analyses, relationship continuity (ie, the PCP ordered the study DXA) was associated with higher average daily calcium intake and likelihood of vitamin D supplementation at 52 weeks. No PCP or primary care clinic factors were associated with osteoporosis care. CONCLUSIONS: The relationship continuity, in which the provider ordering a DXA is the patient's PCP and therefore also presents the results of a DXA, may help to promote patient behaviors associated with good bone health.

Enacted weight stigma and weight self stigma prevalence among 3821 adults.

BACKGROUND: Weight stigma is associated with several negative health issues such as anxiety, depression, maladaptive eating, and metabolic and cardiovascular disease, independent of weight and problematic for individuals of all ages and body sizes. To reduce harmful effects of weight stigma, it is imperative we accurately capture the prevalence of weight stigma in the population to better understand the magnitude of the problem. The purpose of this study was to describe the prevalence of both enacted weight stigma and weight-self stigma and include important contextual factors such as demographic characteristics and the belief about personal controllability of body weight. METHODS: This cross-sectional study included over 3800 adults who completed an online survey that captured their experiences with weight-based discrimination, teasing and beliefs about obesity. Using multivariate logistic regression, we predicted the odds of weight stigma across demographic characteristics and beliefs about obesity. RESULTS: The prevalence of weight stigma in this sample was 57%. We found that the odds of weight discrimination and teasing are higher across BMI categories and that the odds of weight self-stigma are highest among those who are categorized as overweight or obese. Additionally, the odds of weight self-stigma are higher for those who believe individuals are personally responsible for body weight. CONCLUSIONS: Our findings are comprehensive and offer new information crucial to our overall understanding of weight-based stigma and discrimination. Most people have weight stigma and it is prevalent in individuals of all body sizes. This study has significant implications for research and clinical practice.

Infertility Services for Veterans: Policies, Challenges, and Opportunities.

Infertility prevalence and care needs among male and female Veterans are understudied topics. The Veterans Health Administration (VHA) medical benefits package covers full infertility evaluation and many infertility treatments for Veterans but not, by law, for their spouses. In vitro fertilization (IVF) is also specifically excluded from this medical benefits package by regulation. Congress passed a law in 2016 that allowed VHA to provide IVF to Veterans and their legal spouses, and broader infertility benefits to the legal spouse, if the Veteran has a service-connected condition associated with his or her infertility, with some limitations. As the Veteran population becomes increasingly female, research efforts in reproductive health, including infertility, are expanding and evolving. This includes a nationwide study currently underway examining infertility among male and female Veterans and associations with military-related trauma, such as injury, posttraumatic stress disorder, military sexual trauma, and toxin exposure. In this review, we describe the state of the science and policy on infertility care in the VHA along with challenges and opportunities that exist within the VHA system.

Preconception Care in the Veterans Health Administration.

Preconception care (PCC), defined as a set of interventions to help women optimize their health and well-being prior to pregnancy, can improve pregnancy outcomes and is recommended by national organizations including the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists. Women Veterans who use the Department of Veterans Affairs (VA) health care system may face elevated risks of adverse pregnancy and birth outcomes due to a high prevalence of chronic medical and mental health conditions as well as psychosocial stressors including sexual trauma history and intimate partner violence. Many women Veterans of childbearing age experience poverty and homelessness, which are key social determinants of poor reproductive health outcomes. Furthermore, racial/ethnic disparities in maternal and neonatal outcomes are well documented, and nearly half of women Veterans of reproductive age are minority race/ethnicity. High-quality, equitable, patient-centered PCC services to address modifiable risks in this population are therefore a priority for VA. In this article, we provide a brief background of PCC, discuss the health risks of Veterans associated with adverse pregnancy outcomes, and highlight VA initiatives related to PCC. Lastly, we discuss implications and future directions for PCC research and policy within VA and across other health systems.