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  • Prevalence and predictors of shared decision-making in goals-of-care clinician-family meetings for critically ill neurologic patients: a multi-center mixed-methods study

    Fleming, Victoria; Prasad, Abhinav; Ge, Connie; Crawford, Sybil; Meraj, Shazeb; Hough, Catherine L; Lo, Bernard; Carson, Shannon S; Steingrub, Jay; White, Douglas B; et al. (2023-10-21)
    Background: Shared decision-making is a joint process where patients, or their surrogates, and clinicians make health choices based on evidence and preferences. We aimed to determine the extent and predictors of shared decision-making for goals-of-care discussions for critically ill neurological patients, which is crucial for patient-goal-concordant care but currently unknown. Methods: We analyzed 72 audio-recorded routine clinician-family meetings during which goals-of-care were discussed from seven US hospitals. These occurred for 67 patients with 72 surrogates and 29 clinicians; one hospital provided 49/72 (68%) of the recordings. Using a previously validated 10-element shared decision-making instrument, we quantified the extent of shared decision-making in each meeting. We measured clinicians' and surrogates' characteristics and prognostic estimates for the patient's hospital survival and 6-month independent function using post-meeting questionnaires. We calculated clinician-family prognostic discordance, defined as ≥ 20% absolute difference between the clinician's and surrogate's estimates. We applied mixed-effects regression to identify independent associations with greater shared decision-making. Results: The median shared decision-making score was 7 (IQR 5-8). Only 6% of meetings contained all 10 shared decision-making elements. The most common elements were "discussing uncertainty"(89%) and "assessing family understanding"(86%); least frequent elements were "assessing the need for input from others"(36%) and "eliciting the context of the decision"(33%). Clinician-family prognostic discordance was present in 60% for hospital survival and 45% for 6-month independent function. Univariate analyses indicated associations between greater shared decision-making and younger clinician age, fewer years in practice, specialty (medical-surgical critical care > internal medicine > neurocritical care > other > trauma surgery), and higher clinician-family prognostic discordance for hospital survival. After adjustment, only higher clinician-family prognostic discordance for hospital survival remained independently associated with greater shared decision-making (p = 0.029). Conclusion: Fewer than 1 in 10 goals-of-care clinician-family meetings for critically ill neurological patients contained all shared decision-making elements. Our findings highlight gaps in shared decision-making. Interventions promoting shared decision-making for high-stakes decisions in these patients may increase patient-value congruent care; future studies should also examine whether they will affect decision quality and surrogates' health outcomes.
  • Multicomponent Pharmacist Intervention Did Not Reduce Clinically Important Medication Errors for Ambulatory Patients Initiating Direct Oral Anticoagulants

    Kapoor, Alok; Patel, Parth; Mbusa, Daniel; Pham, Thu; Cicirale, Carrie; Tran, Wenisa; Beavers, Craig; Javed, Saud; Wagner, Joann; Swain, Dawn; et al. (2023-09-27)
    Background: Anticoagulants including direct oral anticoagulants (DOACs) are among the highest-risk medications in the United States. We postulated that routine consultation and follow-up from a clinical pharmacist would reduce clinically important medication errors (CIMEs) among patients beginning or resuming a DOAC in the ambulatory care setting. Objective: To evaluate the effectiveness of a multicomponent intervention for reducing CIMEs. Design: Randomized controlled trial. Participants: Ambulatory patients initiating a DOAC or resuming one after a complication. Intervention: Pharmacist evaluation and monitoring based on the implementation of a recently published checklist. Key elements included evaluation of the appropriateness of DOAC, need for DOAC affordability assistance, three pharmacist-initiated telephone consultations, access to a DOAC hotline, documented hand-off to the patient's continuity provider, and monitoring of follow-up laboratory tests. Control: Coupons and assistance to increase the affordability of DOACs. Main measure: Anticoagulant-related CIMEs (Anticoagulant-CIMEs) and non-anticoagulant-related CIMEs over 90 days from DOAC initiation; CIMEs identified through masked assessment process including two physician adjudication of events presented by a pharmacist distinct from intervention pharmacist who reviewed participant electronic medical records and interview data. Analysis: Incidence and incidence rate ratio (IRR) of CIMEs (intervention vs. control) using multivariable Poisson regression modeling. Key results: A total of 561 patients (281 intervention and 280 control patients) contributed 479 anticoagulant-CIMEs including 31 preventable and ameliorable ADEs and 448 significant anticoagulant medication errors without subsequent documented ADEs (0.95 per 100 person-days). Failure to perform required blood tests and concurrent, inappropriate usage of a DOAC with aspirin or NSAIDs were the most common anticoagulant-related CIMEs despite pharmacist documentation systematically identifying these issues when present. There was no reduction in anticoagulant-related CIMEs among intervention patients (IRR 1.17; 95% CI 0.98-1.42) or non-anticoagulant-related CIMEs (IRR 1.05; 95% CI 0.80-1.37). Conclusion: A multi-component intervention in which clinical pharmacists implemented an evidence-based DOAC Checklist did not reduce CIMEs. Nih trial number: NCT04068727.
  • Evaluating nursing students’ outcomes in an educational escape room: Escape a night of rapids!

    Malatesta, Thin Zar; Hebert, Danielle; Cornine, Amanda; Amoah, Rita (2023-09-19)
    An educational escape room (EER) was developed as an innovative strategy for summative evaluation at the end of the first semester in a medical/surgical course within an accelerated nursing program. Learning outcomes were focused on recognizing abnormal vital signs of a decompensating patient, prioritizing nursing interventions, role-playing as a rapid response nurse, collaborating with peers to complete each puzzle, interpreting findings, and discovering medication errors. Debriefing allowed faculty to provide feedback on the achievement of the learning outcomes. Most students agreed that the EER allowed them to meet each learning outcome. This project supported the usefulness of EERs for the evaluation of student learning outcomes in a fast-paced program that may be similar to the speed at which associate degree programs prepare students.
  • Nurses with Physical Disabilities Experiences During Pre-licensure Education

    Mantlow, Kimberly D. (2023-08-15)
    PURPOSE: To describe the pre-licensure nursing educational experience of integration and inclusion among RNs with a physical disability during their education. SPECIFIC AIMS: 1) Describe the access RNs with a physical disability had to academic and social opportunities during their prelicensure education program that contributed to academic and social integration (inclusion). 2). Explore perceptions of RNs with a physical disability regarding inclusion and acceptance of their disability as a valued component of student diversity during their prelicensure education program. 3). Describe the contextual factors and key aspects of connection during the pre-licensure educational experiences of RNs who had a physical disability as positive (Disability-Diversity Connect) or negative and disintegrated (Disability-Diversity Disconnect). FRAMEWORK: This study was guided by The Disability-Diversity Disconnect (DDDM) by Aquino (2016). DESIGN: This study design used was qualitative description. It included semi-structured interviews using an interview guide based on the DDDM. RESULTS: 16 individuals with 14 different physical disabilities participated in this study. During data analysis four themes emerged: I Saved My Energy for Learning, Determination, Wanting to Find My People and Secrets, Living a Double Life which has a subtheme, Fear of Judgement. CONCLUSION: : Identification of factors related to inclusion within the academic environment provides insight for future work to examine the needs of prelicensure nursing students with physical disabilities and the potential to improve their future educational experiences.
  • Prognostic Language in Critical Neurologic Illness: A Multicenter Mixed-Methods Study

    Goss, Adeline; Ge, Connie; Crawford, Sybil; Goostrey, Kelsey; Buddadhumaruk, Praewpannanrai; Hough, Catherine L; Lo, Bernard; Carson, Shannon; Steingrub, Jay; White, Douglas B; et al. (2023-06-08)
    Background and objectives: There are no evidence-based guidelines for discussing prognosis in critical neurologic illness, but in general, experts recommend that clinicians communicate prognosis using estimates, such as numerical or qualitative expressions of risk. Little is known about how real-world clinicians communicate prognosis in critical neurologic illness. Our primary objective was to characterize prognostic language clinicians used in critical neurologic illness. We additionally explored whether prognostic language differed between prognostic domains (e.g., survival, cognition). Methods: We conducted a multicenter cross-sectional mixed-methods study analyzing deidentified transcripts of audio-recorded clinician-family meetings for patients with neurologic illness requiring intensive care (e.g., intracerebral hemorrhage, traumatic brain injury, severe stroke) from 7 US centers. Two coders assigned codes for prognostic language type and domain of prognosis to each clinician prognostic statement. Prognostic language was coded as probabilistic (estimating the likelihood of an outcome occurring, e.g., "80% survival"; "She'll probably survive") or nonprobabilistic (characterizing outcomes without offering likelihood; e.g., "She may not survive"). We applied univariate and multivariate binomial logistic regression to examine independent associations between prognostic language and domain of prognosis. Results: We analyzed 43 clinician-family meetings for 39 patients with 78 surrogates and 27 clinicians. Clinicians made 512 statements about survival (median 0/meeting [interquartile range (IQR) 0-2]), physical function (median 2 [IQR 0-7]), cognition (median 2 [IQR 0-6]), and overall recovery (median 2 [IQR 1-4]). Most statements were nonprobabilistic (316/512 [62%]); 10 of 512 prognostic statements (2%) offered numeric estimates; and 21% (9/43) of family meetings only contained nonprobabilistic language. Compared with statements about cognition, statements about survival (odds ratio [OR] 2.50, 95% CI 1.01-6.18, p = 0.048) and physical function (OR 3.22, 95% 1.77-5.86, p < 0.001) were more frequently probabilistic. Statements about physical function were less likely to be uncertainty-based than statements about cognition (OR 0.34, 95% CI 0.17-0.66, p = 0.002). Discussion: Clinicians preferred not to use estimates (either numeric or qualitative) when discussing critical neurologic illness prognosis, especially when they discussed cognitive outcomes. These findings may inform interventions to improve prognostic communication in critical neurologic illness.
  • Matching medical staff to long term care facilities to respond to COVID-19 outbreak

    Zarei, Hamid Reza; Ghanbarpour Mamaghani, Mahsa; Ergun, Ozlem; Yu, Patricia; Winchester, Leanne; Chen, Elizabeth (2023-06-07)
    Background: Staff shortage is a long-standing issue in long term care facilities (LTCFs) that worsened with the COVID-19 outbreak. Different states in the US have employed various tools to alleviate this issue in LTCFs. We describe the actions taken by the Commonwealth of Massachusetts to assist LTCFs in addressing the staff shortage issue and their outcomes. Therefore, the main question of this study is how to create a central mechanism to allocate severely limited medical staff to healthcare centers during emergencies. Methods: For the Commonwealth of Massachusetts, we developed a mathematical programming model to match severely limited available staff with LTCF demand requests submitted through a designed portal. To find feasible matches and prioritize facility needs, we incorporated restrictions and preferences for both sides. For staff, we considered maximum mileage they are willing to travel, available by date, and short- or long-term work preferences. For LTCFs, we considered their demand quantities for different positions and the level of urgency for their demand. As a secondary goal of this study, by using the feedback entries data received from the LTCFs on their matches, we developed statistical models to determine the most salient features that induced the LTCFs to submit feedback. Results: We used the developed portal to complete about 150 matching sessions in 14 months to match staff to LTCFs in Massachusetts. LTCFs provided feedback for 2,542 matches including 2,064 intentions to hire the matched staff during this time. Further analysis indicated that nursing homes and facilities that entered higher levels of demand to the portal were more likely to provide feedback on the matches and facilities that were prioritized in the matching process due to whole facility testing or low staffing levels were less likely to do so. On the staffing side, matches that involved more experienced staff and staff who can work afternoons, evenings, and overnight were more likely to generate feedback from the facility that they were matched to. Conclusion: Developing a central matching framework to match medical staff to LTCFs at the time of a public health emergency could be an efficient tool for responding to staffing shortages. Such central approaches that help allocate a severely limited resource efficiently during a public emergency can be developed and used for different resource types, as well as provide crucial demand and supply information in different regions and/or demographics.
  • Using Simulation-Based Learning with Standardized Patients (SP) in an Implicit Bias Mitigation Clinician Training Program

    Tjia, Jennifer; Pugnaire, Michele; Calista, Joanne; Eisdorfer, Ethan; Hale, Janet; Terrien, Jill; Valdman, Olga; Potts, Stacy E; Garcia, Maria; Yazdani, Majid; et al. (2023-06-05)
    Objectives: To describe the development and refinement of an implicit bias recognition and management training program for clinical trainees. Methods: In the context of an NIH-funded clinical trial to address healthcare disparities in hypertension management, research and education faculty at an academic medical center used a participatory action research approach to engage local community members to develop and refine a "knowledge, awareness, and skill-building" bias recognition and mitigation program. The program targeted medical residents and Doctor of Nursing Practice students. The content of the two-session training included: didactics about healthcare disparities, racism and implicit bias; implicit association test (IAT) administration to raise awareness of personal implicit bias; skill building for bias-mitigating communication; and case scenarios for skill practice in simulation-based encounters with standardized patients (SPs) from the local community. Results: The initial trial year enrolled n = 65 interprofessional participants. Community partners and SPs who engaged throughout the design and implementation process reported overall positive experiences, but SPs expressed need for greater faculty support during in-person debriefings following simulation encounters to balance power dynamics. Initial year trainee participants reported discomfort with intensive sequencing of in-person didactics, IATs, and SP simulations in each of the two training sessions. In response, authors refined the training program to separate didactic sessions from IAT administration and SP simulations, and to increase safe space, and trainee and SP empowerment. The final program includes more interactive discussions focused on identity, race and ethnicity, and strategies to address local health system challenges related to structural racism. Conclusion: It is possible to develop and implement a bias awareness and mitigation skills training program that uses simulation-based learning with SPs, and to engage with local community members to tailor the content to address the experience of local patient populations. Further research is needed to measure the success and impact of replicating this approach elsewhere.
  • From COVID-19 Vaccine Hesitancy to Vaccine Acceptance: Results of a Longitudinal Survey

    Fisher, Kimberly A; Nguyen, Ngoc; Fouayzi, Hassan; Crawford, Sybil; Singh, Sonal; Dong, May; Wittenberg, Ruth; Mazor, Kathleen M (2023-05-27)
    Objectives: COVID-19 vaccines are widely available, but uptake is suboptimal. To develop strategies to increase vaccination rates, we sought to (1) characterize adults initially hesitant to be vaccinated for COVID-19 who later received the vaccine and (2) identify factors associated with their vaccination decision. Methods: In January 2021, we conducted an online survey of US adults via Prolific that assessed vaccination intent, COVID-19-related knowledge and attitudes, and demographic characteristics. In May 2021, we recontacted respondents to assess vaccination status and factors influencing their vaccination decision. We used χ2 statistics and t tests to examine associations between respondents' vaccination status and their characteristics, knowledge, and attitudes. We analyzed reasons for vaccination using thematic analysis. Results: Of 756 initially vaccine-hesitant respondents, 529 (70.0%) completed the follow-up survey. Nearly half of those initially not sure about vaccination (47.3%, 112 of 237) were vaccinated at follow-up, while 21.2% (62 of 292) of those initially planning not to be vaccinated were vaccinated at follow-up. Of those initially not sure, higher educational attainment, greater knowledge of COVID-19, and a doctor's recommendation were associated with vaccination. Of those initially intending not to be vaccinated, male sex, Democratic political affiliation, receipt of an influenza shot within 5 years, being more worried about COVID-19, and having greater COVID-19 knowledge were associated with increased likelihood of being vaccinated. Of 167 respondents who gave reasons for vaccination, protecting oneself and others (59.9%), practical issues (29.9%), social influences (17.4%), and vaccine safety (13.8%) were the main reasons. Conclusion: Providing information on the protective value of vaccination, implementing rules that make remaining unvaccinated burdensome, making vaccination easy, and providing social support may influence vaccine-hesitant adults to accept vaccination.
  • Ready for Action: A National Study of Pediatric Healthcare Professionals' Attitudes and Beliefs About Weight Stigma

    Turner, Samantha (2023-05-26)
    PURPOSE: To quantify pediatric healthcare professionals’ (HCPs’) attitudes and beliefs about weight stigma and levels of implicit and explicit weight bias and describe interventions that are most supported by pediatric HCPs. SPECIFIC AIMS: 1) Determine the distribution of weight bias among pediatric HCPs and identify associations between characteristics and weight bias. 2) Examine attitudes and beliefs of pediatric HCPs about weight stigma and identify associations between characteristics and attitudes/beliefs. 3) Investigate the relationship between HCPs’ weight bias and attitudes/beliefs. 4) Identify interventions most supported by pediatric HCPs. Framework: The Health Stigma Discrimination Framework guided this study. DESIGN: This study utilized a cross-sectional survey of pediatric HCPs. Participants completed the Implicit Association Test (IAT), the Crandall Anti-Fat Attitudes Questionnaire (CAAQ), a researcher-designed questionnaire (BAWSQ), and demographic questions. RESULTS: The sample exhibited a moderate implicit bias (M=0.59, SD=0.41) and explicit bias (M=38.95, SD=10.9). Participants generally agreed with BAWSQ statements and broadly supported interventions. The most-supported intervention was continuing education units (CEUs) for anti-weight bias activities (n=144, 81.36%). Implicit bias was associated with more years in practice, occupation, and age. Explicit bias was associated with practice setting. As explicit bias increased, so did agreement with BAWSQ question 1 (r=0.208, p=0.005), and disagreement with BAWSQ questions 3 and 4 (r=-0.237, p<0.005; r=-0.394, p<0.001, respectively). CONCLUSION: Weight bias is prevalent in pediatric healthcare and pediatric HCPs are invested in approaches to reduce weight bias. Future interventions should be brief, concise, and should aim to broaden awareness of pediatric HCPs about the consequences of weight bias.
  • Population-level policy recommendations for the prevention of disordered weight control behaviors: A scoping review

    Raffoul, Amanda; Turner, Samantha L; Salvia, Meg G; Austin, S Bryn (2023-04-25)
    Objective: The aim of this scoping review was to identify recommendations and gaps in knowledge surrounding the prevention of disordered weight control behaviors (DWCBs) through policy. Method: A search was conducted in several databases to identify English language articles that described an active policy, recommendation, guideline, or educational curriculum that could be implemented by governments or regulatory bodies to prevent DWCBs or related constructs (e.g., weight stigma, body dissatisfaction). Two researchers independently screened articles with oversight from a third researcher. Data were extracted from the final sample (n = 65) and analyzed qualitatively across all articles and within the domains of education, public policy, public health, industry regulation, and media. Results: Only a single empirical evaluation of an implemented policy to reduce DWCBs was identified. Over one-third of articles proposed recommendations relating to industry regulation and media (n = 24, 36.9%), followed by education (n = 21, 32.3%), public policy (n = 19, 29.2%), and public health (n = 10, 15.4%). Recommendations included school-based changes to curricula, staff training, and anti-bullying policies; legislation to ban weight discrimination; policies informed by strategic science; collaboration with researchers from other fields; de-emphasizing weight in health communications; diversifying body sizes and limiting modified images in media; and restricting the sale of weight-loss supplements. Discussion: The findings of this review highlight gaps in empirically evaluated policies to reduce DWCBs but also promising policy recommendations across several domains. Although some policy recommendations were supported by empirical evidence, others were primarily based on experts' knowledge, highlighting the need for greater research on population-level DWCBs prevention through policy. Public significance: Our scoping review of the evidence on policies for the prevention of disordered weight control behaviors identified several recommendations across the domains of education, public policy, public health, and industry regulation and media. Although few empirical investigations of implemented policies have been conducted, expert recommendations for policies to prevent disordered weight control behaviors among populations are plentiful and warrant future consideration by researchers and policymakers alike.
  • Hope for the Future: Key Informants’ Perspectives on HIV Prevention in Dominican Republic Batey Communities

    Filiau, Alaina (2023-04-18)
    Purpose: The purpose of this study, was to understand the interlocking spheres of cultural identity and health behaviors relating to HIV prevention within the batey communities. Specific Aims: Explore key informants’ perceptions of cultural identity that influence HIV prevention including relationships, expectations, and cultural empowerment among persons, extended family, and neighborhoods. Explore key informants’ perceptions of the cultural factors that enable and nurture protective health behaviors relating to HIV prevention among the DR batey communities. Describe key informants’ perceptions of the positive, existential, and negative dimensions of DR batey culture empowerment with the goal of promoting healthy behaviors for HIV prevention in batey communities. Framework: The PEN-3 Model by Airhihenbuwa provided the theoretical framework as a culture-centered approach to understanding cultural context relating to health behaviors. Design: A qualitative descriptive design with maximum variation was utilized, and data was analyzed using qualitative content analysis. Semi-structured qualitative interviews were completed with key informants within the La Romana region of the Dominican Republic. Results: Semi-structured qualitative interviews were conducted with 12 individuals.
  • Diagnoses Associated with Intellectual and Developmental Disabilities in Adult Decedents: A Secondary Analysis of Healthcare Cost and Utilization Project National Inpatient Sample (HCUP/NIS) Data

    Briere, Heather (2023-02-17)
    Purpose: To identify primary and secondary diagnoses preceding death among adults with and without IDD who died during hospitalization. Specific Aims: 1) to describe the commonly reported base diagnostic related groups preceding death among decedents with and without IDD who died during hospitalization in 2019, 2) to determine which base-DRGs had a higher prevalence rate among adults with IDD than among adults without IDD, controlling for age, gender, race, urbanicity of person’s residence, US census division of hospital, and mean income of person’s zip code, and 3) to use the base-DRGs and ICD-10-CMs to examine the conditions of the Fatal Four/Five as conditions of concern preceding death in decedents with and without IDD. Framework: The NIMHD Minority Health and Health Disparities Research Framework. Design: A secondary data analysis using the 2019 Healthcare Cost and Utilization Project National (Nationwide) Inpatient Sample (HCUP-NIS). Results: Identified fourteen primary diagnoses at the time of death for decedents with IDD that are represented at a higher percentage than for decedents without IDD and have a significant odds ratio for IDD diagnosis. Conclusion: A new set of conditions is proposed to assist nurses in reducing preventable deaths in decedents with IDD. Dehydration, GI obstruction, respiratory infection, seizures, and sepsis, will be known as the IDD Concerning Conditions. Aspiration, constipation, and GERD, the IDD Contributing Conditions, are conditions that do not cause death in themselves but contribute to the development of at least one of the IDD Concerning Conditions, which do cause death.
  • Implementation of educational escape rooms in a nurse practitioner doctoral curriculum

    Hebert, Danielle (2023-01-26)
    Escape rooms have gained popularity as a means for team building while working to accurately complete challenging puzzles to 'escape' the room. The use of escape rooms is starting to emerge in healthcare education, including nursing, medicine, dentistry, pharmacology, and psychology. An escape room intensive was created and piloted using the Educational Escape Room Development Guide during the second year of the DNP program. The objective was to challenge their clinical judgment and critical thinking as they solved a series of puzzles created to provide hints for resolving a complex patient scenario. All faculty (n = 7) and most students (96 %, n = 26/27) felt the activity contributed to students' learning process while all students and the majority of faculty (86 %, 6/7) strongly agreed that content was relevant to develop decision making skills. Educational escape rooms can provide engaging, innovative learning to support development of critical thinking and clinical judgment.
  • Managing broken expectations after a diagnosis of fetal anomaly

    Theroux, Rosemary T.; Hersperger, Cheryl L. (2022-12-31)
    The prenatal diagnosis of a fetal anomaly is unexpected, and for many parents it is devastating. It is considered a traumatic perinatal event that presents a crisis for parents. Expectant parents dealing with a lethal anomaly are particularly at increased risk for perinatal depression, anxiety, and traumatic stress. A growing number of qualitative researchers have examined the experience of fetal anomaly. Despite the accumulating knowledge, theory has not been developed. The purpose of this study is to analyze and synthesize evidence drawn from grounded theory research in order to develop a theory that describes and explains the process parents use to manage the diagnosis and predict their needs. A systematic search was conducted in 5 databases. Fourteen grounded theory research articles were chosen and were analyzed with grounded theory methods. Parents' expectations about pregnancy and future parenting were broken with the diagnosis of a fetal anomaly. Parents use a six-stage process of Repositioning to work through the problem and direct their course on the best new pathway for their family. Both personal and situational conditions influenced the decisions and management strategies used by the family. The factors that enhance parents’ repositioning can facilitate the development of interventions to improve the care for these families.
  • Mental Illness Knowledge and Stigma of Jamaican Diaspora & First-Generation Jamaican Americans

    Nyakako, Rose Marie (2022-12-15)
    PURPOSE: To describe U.S. Jamaican diasporan and first-generation Jamaican Americans knowledge of and stigma towards mental illness. SPECIFIC AIMS: 1. Describe U.S. dwelling Jamaican diaspora and first-generation Jamaican Americans knowledge of mental illness and stigma towards mental illness with identification of drivers and facilitators of stigma. 2. Elicit descriptors used by Jamaican diaspora and first-generation Jamaican Americans to describe mental illness. 3. Determine association of mental illness stigma and mental illness knowledge, to age, gender, education, employment, religiosity, years living in the U.S., socioeconomic status, personal history of mental illness, and family member with mental illness. FRAMEWORK: The Health Stigma and Discrimination Framework. DESIGN: Cross-sectional descriptive survey. RESULTS: Jamaican diaspora years have less knowledge (mean 97.25, SD 10.27) than Jamaican Americans (mean 104.24, SD 7.74; p =.001). Participants > 40 years had less knowledge (mean 97.05, SD 9.54) than those < 40 years (mean 102.08, SD 10.95; p =.003). Jamaican diaspora years have more stigma (mean -.52, SD .76) than Jamaican Americans (mean -1.10, SD .73; p < .001). Participants > 40 years had more stigma (mean -.48, SD .69) than those < 40 years (mean 1.02, SD .87; p <.001). CONCLUSION: Older adults have less knowledge of mental illness and more stigma. Jamaican diaspora has less knowledge and more stigma than First-generation Jamaican Americans. Greater mental illness knowledge is associated with less stigma providing support for ongoing efforts to increase public knowledge of mental illness with added emphasis on word choice/terms used when talking about people with mental illness. PURPOSE: To describe U.S. Jamaican diasporan and first-generation Jamaican Americans knowledge of and stigma towards mental illness. SPECIFIC AIMS: 1. Describe U.S. dwelling Jamaican diaspora and first-generation Jamaican Americans knowledge of mental illness and stigma towards mental illness with identification of drivers and facilitators of stigma. 2. Elicit descriptors used by Jamaican diaspora and first-generation Jamaican Americans to describe mental illness. 3. Determine association of mental illness stigma and mental illness knowledge, to age, gender, education, employment, religiosity, years living in the U.S., socioeconomic status, personal history of mental illness, and family member with mental illness. FRAMEWORK: The Health Stigma and Discrimination Framework. DESIGN: Cross-sectional descriptive survey. RESULTS: Jamaican diaspora years have less knowledge (mean 97.25, SD 10.27) than Jamaican Americans (mean 104.24, SD 7.74; p =.001). Participants > 40 years had less knowledge (mean 97.05, SD 9.54) than those < 40 years (mean 102.08, SD 10.95; p =.003). Jamaican diaspora years have more stigma (mean -.52, SD .76) than Jamaican Americans (mean -1.10, SD .73; p < .001). Participants > 40 years had more stigma (mean -.48, SD .69) than those < 40 years (mean 1.02, SD .87; p <.001). CONCLUSION: Older adults have less knowledge of mental illness and more stigma. Jamaican diaspora has less knowledge and more stigma than First-generation Jamaican Americans. Greater mental illness knowledge is associated with less stigma providing support for ongoing efforts to increase public knowledge of mental illness with added emphasis on word choice/terms used when talking about people with mental illness.
  • Expanding Latent Tuberculosis Infection Testing and Treatment in Massachusetts Primary Care Clinics via the ECHO Model

    Szkwarko, Daria; Urbanowski, Michael E; Thal, Rebecca; Iyer, Patricia; Foley, Susan; Randall, Liisa M; Bernardo, John; Savageau, Judith A.; Cochran, Jennifer (2022-12-01)
    Introduction/objectives: In the US, reactivation of latent tuberculosis infection (LTBI) accounts for 80% of new cases. In 2016, the US Preventive Services Task Force provided a new recommendation that primary care providers (PCPs) should conduct LTBI screening, whereas in the past, LTBI cases were evaluated and treated by specialty providers. This shift in care revealed knowledge gaps surrounding LTBI treatment among PCPs. This study assessed changes in PCPs' confidence for performing key aspects of LTBI care before and after participation in an LTBI Extension for Community Healthcare Outcomes (ECHO) course. Methods: The ECHO Model™ is an evidence-based telementoring intervention. Participants were primary care team members from clinics throughout Massachusetts who voluntarily enrolled in the ECHO course. In this mixed-methods evaluation, primary outcomes were PCP self-reported confidence changes by pre- and post-course surveys and post-course semi-structured interviews. Results: Twenty PCPs (43% of registered PCPs) attended at least 3 of the 6 sessions and 24 PCPs (31% of registered PCPs) completed at least one survey. Confidence increased in selecting a test (P = .004), interpreting tuberculosis infection test results (P = .03), and selecting a treatment regimen (P = .004). Qualitative interviews with 3 PCPs revealed practice changes including switching to interferon gamma release assays for testing and using rifampin for treatment. Conclusions: Use of the ECHO model to train PCPs in LTBI management is feasible and efficacious. For continuing medical education, ECHO courses can be leveraged to reduce health disparities in settings where PCPs' lack of familiarity about a treatment topic contributes to poor health outcomes.
  • The Impact of COVID-19 on the Behavioral Health of Massachusetts Tribal Communities

    Aronowitz, Teri; Woods, Cedric; Kim, BoRam; Frisard, Christine F.; Beatriz, Elizabeth; Cardoso, Lauren; Lin, Ta-Wei; Stack, Caroline; Lemon, Stephenie C. (2022-11-07)
    Background: American Indian/Alaskan Native (AI/AN) individuals were 3.5 times more likely to be hospitalized from the virus compared to other race/ethic groups (CDC, 2021). Despite being disproportionately impacted by COVID-19, the experiences of the AI/AN population during the pandemic have not been documented. There are approximately 93,123 individuals in Massachusetts (MA) that identify as AI/AN (U.S. Census, 2020). This study examined the impact of COVID-19 on the behavioral health of the MA AI/AN population. Methods: A web-based survey was completed by 452 AI/ANs. A focus group with members of the AN/AI/AN (n=10) community was conducted to provide insights into the survey results. Individuals were recruited through the Institute of New England Native American Studies research team’s Community Advisory Board. Results: Forty-two percent of sample were between 45-64 years of age, female (77.2%), and identified as AN/AN in combination with another race (85%). Almost half of AI/AN participants had 15 or more days of poor mental health in the past month with rates highest among younger individuals. Forty-four percent reported that their substance use was a lot or somewhat more than pre-pandemic. Focus group findings indicated that the pandemic exacerbated (1) behavioral health challenges; (2) isolation from others and from AI/AN organizations; (3) telehealth was helpful to some; but (4) 30% had limited broadband access. Conclusion & Implications: The AI/AN community in MA has experienced devastating behavioral health outcomes during the pandemic. Urgent action is needed to address with crisis. Funding for risk-reducing programs and culturally specific treatment interventions are needed.
  • Use of a Rapid Qualitative Method to Inform the Development of a Text Messaging Intervention for People With Serious Mental Illness Who Smoke: Formative Research Study

    Nagawa, Catherine S; Lane, Ian A; McKay, Colleen E; Kamberi, Ariana; Shenette, Lisa L; Kelly, Megan M; Davis, Maryann; Sadasivam, Rajani S (2022-11-07)
    Background: People with serious mental illness are disproportionately affected by smoking and face barriers to accessing smoking cessation treatments in mental health treatment settings. Text-based interventions are cost-effective and represent a widely accessible approach to providing smoking cessation support. Objective: We aimed to identify key factors for adapting text-based cessation interventions for people with serious mental illness who smoke. Methods: We recruited 24 adults from mental health programs who had a serious mental illness and currently smoked cigarettes or had quit smoking within the past 5 years. We then conducted virtual qualitative interviews between November 2020 and August 2021. Data were analyzed using the rapid thematic analytic approach. Results: We identified the following 3 major themes: (1) interplay between smoking and having a serious mental illness, (2) social contextual factors of smoking in adults with serious mental illness, and (3) smoking and quitting behaviors similar to the general population. Participants reported barriers and facilitators to quitting across the 3 themes. Within the "interplay between smoking and having a serious mental illness" theme, barriers included smoking to manage stress and mental health symptoms, and facilitators to quitting included the awareness of the harm of smoking on mental health and patient-provider discussions on smoking and mental health. In the "social contextual factors of smoking in adults with serious mental illness" theme, barriers included high social acceptability of smoking among peers. Positive support and the combined social stigma of smoking and having a mental health condition outside of peer groups motivated individuals to quit. Some participants indicated that low exposure to other smokers during the COVID-19 pandemic helped them to engage in cessation efforts. In the "smoking and quitting behaviors similar to the general population" theme, barriers included smoking after eating, having coffee, drinking alcohol, and experiencing negative social support, and facilitators included health concerns, improvement in the general quality of life, and use of evidence-based tobacco treatments when available. Conclusions: People with serious mental illness often smoke to cope with intense emotional states, manage mental health symptoms, or maintain social bonds. Text message content emphasizing equally effective and less harmful ways for stress reduction and mental health symptom management may improve quit rates in individuals with serious mental illness.
  • Non-COVID-19 hospitalizations: patients’ experiences during the COVID-19 pandemic

    Patrick, Julia (2022-11-02)
    The purpose of this Qualitative Descriptive study was to describe the experience of hospitalized adults during the pandemic who did not have COVID-19. Semi-structured interviews were conducted with 20 English-speaking adults who were hospitalized on a medical or surgical floor after April 1, 2020 and were negative for COVID-19 throughout their entire hospital stay. The interview questions focused on the overall hospital experience, the nurse’s role in their experience, comfort needs, and the experience of having comfort needs met during the hospitalization. Conventional content analysis of the transcribed transcripts revealed five main themes related to the hospital experience: I don’t expect the hospital to be comfortable; I was always tense; Wanting human connection; Communication is important; and Nurses are busy. An unpleasant environment, longing for comfort from family and nurses, a perception that the nurses were too busy, feelings of being isolated from others and the world, and experiencing fear and anxiety were all elements of the hospital experience during the COVID-19 pandemic. These findings identified a need for targeted practice, research, and education to improve patient comfort in the physical, psycho-spiritual, sociocultural, and environmental contexts. This is important as we look toward improving the overall patient experience during hospitalization.
  • COVID-19 Test Us: A Case for Embedding Ethics and Regulatory Expertise

    Taylor, Holly A.; Hale, Janet F.; Centola, Michael; Blodgett, Allison (2022-11-01)
    A key aspect of the National Institutes of Health (NIH) funded Rapid Acceleration of Diagnostics (RADx) Tech program was an active Clinical Studies Core including Committees with unique expertise to facilitate the development and implementation of studies to test novel diagnostic devices for Covid-19. The Ethics and Human Subjects Oversight Team (EHSO) was tasked to provide ethics and regulatory expertise to stakeholders in the RADx Tech effort. The EHSO developed a set of Ethical Principles to guide the overall effort and provided consultation on a wide range of ethical and regulatory concerns. Having access to a pool of experts with ethical and regulatory knowledge who met weekly to tackle issues of importance to the investigators was critical to the overall success of the project.

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