Publications by authors named "Emily Hurley"

38 Publications

Long-acting reversible contraceptives (LARCs) as harm reduction: a qualitative study exploring views of women with histories of opioid misuse.

Harm Reduct J 2021 Aug 4;18(1):83. Epub 2021 Aug 4.

Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA.

Background: The sharp rise in opioid use disorder (OUD) among women coupled with disproportionally high rates of unintended pregnancy have led to a four-fold increase in the number of pregnant women with OUD in the United States over the past decade. Supporting intentional family planning can have multiple health benefits and reduce harms related to OUD but requires a comprehensive understanding of women's perspectives of preventing unintended pregnancies. The purpose of this study was to comprehensively evaluate the knowledge, attitudes and experiences as they relate to seeking contraception, particularly LARCs, among women with active or recovered opioid misuse.

Methods: In-depth interviews and focus group discussions with 36 women with current or past opioid misuse were recorded and transcribed. Transcripts were coded by ≥ 2 investigators. Themes related to contraceptive care seeking were identified and contextualized within the Health Belief Model.

Results: Our analysis revealed seven interwoven themes that describe individual level factors associated with contraceptive care seeking in women with current or past opioid misuse: relationship with drugs, reproductive experiences and self-perceptions, sexual partner dynamics, access, awareness of options, healthcare attitudes/experiences, and perceptions of contraception efficacy/ side effects. Overall, perceived susceptibility and severity to unintended pregnancy varied, but most women perceived high benefits of contraception, particularly LARC. However, perceived barriers were too high for most to obtain desired contraception to support family planning intentions.

Conclusions: The individual-level factors identified should inform the design of integrated services to promote patient-centered contraceptive counseling as a form of harm reduction. Interventions should reduce barriers to contraceptive access, particularly LARCs, and establish counseling strategies that use open, non-judgmental communication, acknowledge the continuum of reproductive needs, explore perceived susceptibility to pregnancy, and utilize peer educators.
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http://dx.doi.org/10.1186/s12954-021-00532-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8335991PMC
August 2021

Provider Perspectives on Navigating Relationship Challenges in Assisting HIV-Affected Couples to Meet Their Reproductive Goals: Lessons Learned from a Safer Conception Counseling Intervention in Uganda.

AIDS Behav 2021 Jul 29. Epub 2021 Jul 29.

Schools of Medicine and Pharmacy, Childrens Mercy Research Institute, University of Missouri, Kansas, MO, USA.

In Uganda, 60% of HIV-affected couples are serodiscordant, many of whom want children. There is a need to assess their reproductive intentions and provide appropriate services that limit transmission risks while meeting reproductive goals. Our Choice intervention engaged male and female HIV-infected clients and their partners in safer conception counseling (SCC) or family planning based on their childbearing decision. We report findings of provider experiences and recommendations for engaging couples in SCC. The intervention was implemented in four clinics offering either SCC1, an intensive training and supervision arm, or SCC2, utilizing the Ministry of Health's standard approach. Qualitative interviews were conducted at 12 (N = 23) and 24 months (N = 25) after initiation of the intervention. Many partners attended at least some SCC sessions, although engaging male partners was more challenging. Providers reported partner involvement improved understanding and facilitated successful implementation of SCM, whereas confusion and challenges were common when the client participated alone. Providers shared successful strategies for engaging male partners.
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http://dx.doi.org/10.1007/s10461-021-03397-4DOI Listing
July 2021

Challenges in genetic testing: clinician variant interpretation processes and the impact on clinical care.

Genet Med 2021 Jul 13. Epub 2021 Jul 13.

Genomic Medicine Center, Children's Mercy Hospital, Kansas City, MO, USA.

Purpose: Efforts have been made to standardize laboratory variant interpretation, but clinicians are ultimately tasked with clinical correlation and application of genetic test results in patient care. This study aimed to explore processes clinicians utilize when reviewing and returning genetic test results, and how they impact patient care.

Methods: Medical geneticists, genetic counselors, and nongenetics clinicians from two Midwestern states completed surveys (n = 98) and in-depth interviews (n = 29) on practices of reviewing and returning genetic test results. Retrospective chart review (n = 130) examined discordant interpretations and the impact on care.

Results: Participants reported variable behaviors in both reviewing and returning results based on factors such as confidence, view of role, practice setting, and relationship with the lab. Providers did not report requesting changes to variant classifications from laboratories, but indicated relaying conflicting classifications to patients in some cases. Chart reviews revealed medically impactful differences in interpretation between laboratories and clinicians in 18 (13.8%) records.

Conclusion: Clinician practices for reviewing and integrating genetic test results into patient care vary within and between specialties and impact patient care. Strategies to better incorporate both laboratory and clinician expertise into interpretation of genetic results could result in improved care across providers and settings.
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http://dx.doi.org/10.1038/s41436-021-01267-xDOI Listing
July 2021

Huntingtin and the Synapse.

Front Cell Neurosci 2021 15;15:689332. Epub 2021 Jun 15.

Division of Biomedical Sciences, Faculty of Medicine, Memorial University, St. John's, NL, Canada.

Huntington disease (HD) is a monogenic disease that results in a combination of motor, psychiatric and cognitive symptoms. HD is caused by a CAG trinucleotide repeat expansion in the huntingtin () gene, which results in the production of a pathogenic mutant HTT protein (mHTT). Although there is no cure at present for HD, a number of RNA-targeting therapies have recently entered clinical trials which aim to lower mHTT production through the use of antisense oligonucleotides (ASOs) and RNAi. However, many of these treatment strategies are non-selective in that they cannot differentiate between non-pathogenic wild type HTT (wtHTT) and the mHTT variant. As HD patients are already born with decreased levels of wtHTT, these genetic therapies may result in critically low levels of wtHTT. The consequence of wtHTT reduction in the adult brain is currently under debate, and here we argue that wtHTT loss is not well-tolerated at the synaptic level. Synaptic dysfunction is an extremely sensitive measure of subsequent cell death, and is known to precede neurodegeneration in numerous brain diseases including HD. The present review focuses on the prominent role of wtHTT at the synapse and considers the consequences of wtHTT loss on both pre- and postsynaptic function. We discuss how wtHTT is implicated in virtually all major facets of synaptic neurotransmission including anterograde and retrograde transport of proteins to/from terminal buttons and dendrites, neurotransmitter release, endocytic vesicle recycling, and postsynaptic receptor localization and recycling. We conclude that wtHTT presence is essential for proper synaptic function.
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http://dx.doi.org/10.3389/fncel.2021.689332DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8239291PMC
June 2021

Recovering from substance use disorders during the early months of the COVID-19 pandemic: A mixed-methods longitudinal study of women in Kansas City.

J Subst Abuse Treat 2021 10 20;129:108378. Epub 2021 Mar 20.

Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA; Emergency Medicine, Children's Mercy Kansas City, Kansas City, MO, USA.

Aims: During the early months of the U.S. COVID-19 outbreak, women suffered disproportionate burdens of pandemic-related psychological and economic distress. We aimed to describe the experiences of women in substance use disorder (SUD) recovery programs by (1) exploring the pandemic's impact on their lives, sobriety, and recovery capital and (2) tracking COVID-19 perceptions and preventative behaviors.

Methods: We conducted monthly semistructured interviews with women in residential and outpatient SUD recovery programs in Kansas City in April, May, and June 2020. Participants described the pandemic's impact on their life and sobriety and completed survey items on factors related to COVID-19 preventative behaviors. We interpreted qualitative themes longitudinally alongside quantitative data.

Results: In 64 interviews, participants (n = 24) described reduced access to recovery capital, or resources that support sobriety, such as social relationships, housing, employment, and health care. Most experienced negative impacts on their lives and feelings of stability in March and April but maintained sobriety. Four women described relapse, all attributed to pandemic stressors. Participants described relief related to societal re-opening in May and June, and increased engagement with their communities, despite rising infection rates.

Conclusions: For women recovering from SUDs during COVID-19, securing recovery capital often meant assuming greater COVID-19 risk. As substance use appeared to have increased during the pandemic and COVID-19 transmission continues, public health planning must prioritize adequate and safe access to recovery capital and timely distribution of vaccines to people struggling with SUDs.
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http://dx.doi.org/10.1016/j.jsat.2021.108378DOI Listing
October 2021

Loss of Mafb and Maf distorts myeloid cell ratios and disrupts fetal mouse testis vascularization and organogenesis†.

Biol Reprod 2021 May 18. Epub 2021 May 18.

Division of Reproductive Sciences, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.

Testis differentiation is initiated when Sry in pre-Sertoli cells directs the gonad toward a male-specific fate. Sertoli cells are essential for testis development, but cell types within the interstitial compartment, such as immune and endothelial cells, are also critical for organ formation. Our previous work implicated macrophages in fetal testis morphogenesis, but little is known about genes underlying immune cell development during organogenesis. Here we examine the role of the immune-associated genes Mafb and Maf in mouse fetal gonad development, and we demonstrate that deletion of these genes leads to aberrant hematopoiesis manifested by supernumerary gonadal monocytes. Mafb; Maf double knockout embryos underwent initial gonadal sex determination normally, but exhibited testicular hypervascularization, testis cord formation defects, Leydig cell deficit, and a reduced number of germ cells. In general, Mafb and Maf alone were dispensable for gonad development; however, when both genes were deleted, we observed significant defects in testicular morphogenesis, indicating that Mafb and Maf work redundantly during testis differentiation. These results demonstrate previously unappreciated roles for Mafb and Maf in immune and vascular development and highlight the importance of interstitial cells in gonadal differentiation.
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http://dx.doi.org/10.1093/biolre/ioab098DOI Listing
May 2021

"Our Choice" improves use of safer conception methods among HIV serodiscordant couples in Uganda: a cluster randomized controlled trial evaluating two implementation approaches.

Implement Sci 2021 04 15;16(1):41. Epub 2021 Apr 15.

Children's Mercy Research Institute, Children's Mercy Kansas City, University of Missouri - Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA.

Background: Safer conception counseling (SCC) to promote the use of safer conception methods (SCM) is not yet part of routine family planning or HIV care. Guidelines for the use of SCM have been published, but to date there are no published controlled evaluations of SCC. Furthermore, it is unknown whether standard methods commonly used in resource constrained settings to integrate new services would be sufficient, or if enhanced training and supervision would result in a more efficacious approach to implementing SCC.

Methods: In a hybrid, cluster randomized controlled trial, six HIV clinics were randomly assigned to implement the SCC intervention Our Choice using either a high (SCC1) or low intensity (SCC2) approach (differentiated by amount of training and supervision), or existing family planning services (usual care). Three hundred eighty-nine HIV clients considering childbearing with an HIV-negative partner enrolled. The primary outcome was self-reported use of appropriate reproductive method (SCM if trying to conceive; modern contraceptives if not) over 12 months or until pregnancy.

Results: The combined intervention groups used appropriate reproductive methods more than usual care [20.8% vs. 6.9%; adjusted OR (95% CI)=10.63 (2.79, 40.49)], and SCC1 reported a higher rate than SCC2 [27.1% vs. 14.6%; OR (95% CI)=4.50 (1.44, 14.01)]. Among those trying to conceive, the intervention arms reported greater accurate use of SCM compared to usual care [24.1% vs. 0%; OR (95% CI)=91.84 (4.94, 1709.0)], and SCC1 performed better than SCC2 [34.6% vs. 11.5%; OR (95% CI)=6.43 (1.90, 21.73)]. The arms did not vary on modern contraception use among those not trying to conceive. A cost of $631 per person was estimated to obtain accurate use of SCM in SCC1, compared to $1014 in SCC2.

Conclusions: More intensive provider training and more frequent supervision leads to greater adoption of complex SCM behaviors and is more cost-effective than the standard low intensity implementation approach.

Trial Registration: Clinicaltrials.gov, NCT03167879 ; date registered May 23, 2017.
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http://dx.doi.org/10.1186/s13012-021-01109-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8048255PMC
April 2021

Inhibition of Ref(2)P, the Drosophila homologue of the p62/SQSTM1 gene, increases lifespan and leads to a decline in motor function.

BMC Res Notes 2021 Feb 8;14(1):53. Epub 2021 Feb 8.

Department of Biology, Memorial University of Newfoundland, St. Johns', NL, A1B 3X9, Canada.

Objective: Sequestosome 1 (p62/SQSTM1) is a multifunctional scaffold/adaptor protein encoded by the p62/SQSTM1 gene with function in cellular homeostasis. Mutations in the p62/SQSTM1 gene have been known to be associated with patients with amyotrophic lateral sclerosis (ALS), frontotemporal dementia (FTD), and Parkinson disease (PD). The aim of the present study was to create a novel model of human neurogenerative disease in Drosophila melanogaster by altering the expression of Ref(2)P, the Drosophila orthologue of the human p62/SQSTM1 gene. Ref(2)P expression was altered in all neurons, the dopaminergic neurons and in the motor neurons, with longevity and locomotor function assessed over time.

Results: Inhibition of Ref(2)P resulted in a significantly increased median lifespan in the motor neurons, followed by a severe decline in motor skills. Inhibition of Ref(2)P in the dopaminergic neurons resulted in a significant, but minimal increase in median lifespan, accompanied by a drastic decline in locomotor function. Inhibition of Ref(2)P in the ddc-Gal4-expressing neurons resulted in a significant increase in median lifespan, while dramatically reducing motor function.
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http://dx.doi.org/10.1186/s13104-021-05462-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7871602PMC
February 2021

Young Adult Males' Perspectives of Male Hormonal Contraception.

South Med J 2021 02;114(2):73-76

From the Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio and the Ohio State University Fisher College of Business, Columbus, Ohio.

Objective: To evaluate the willingness of young adult males to use male hormonal contraception and to determine the most desirable formulation.

Methods: An institutional review board-approved survey measuring the willingness to use MHC was dispersed to two distinct populations: University of Cincinnati postgraduate programs and Cincinnati Health Department clinics. Questions on the survey allowed for the collection of demographic characteristics, as well as the preferred method of MHC, and concerns regarding potential adverse effects. This survey was directed at young adult males; therefore, only male participants who were 18 to 35 years old were included for analysis. Results were reported as frequencies in each group and χ analyses were performed to compare groups, with a < 0.05 considered significant.

Results: Of 162 total survey participants, 45% would use MHC, whereas 30.9% were unsure and 23.5% would not use MHC. Overall, the University of Cincinnati survey population was more likely to be interested in using MHC than the Cincinnati Health Department population ( < 0.05). In both populations, most were interested in using the injectable form. Cited concerns deterring participants from using MHC were different between these two populations, with University of Cincinnati participants more frequently expressing concerns about possible failure of the contraceptive method, whereas Cincinnati Health Department participants had concerns about potential adverse effects ( < 0.001).

Conclusions: There is significant interest among young adult males in using various forms of MHC, especially in injectable form. Differences in views of MHC were seen in two distinct male populations. Specifically, males who achieved a higher level of education, were employed, or in a relationship were found to more frequently be willing to use MHC. With further research and funding, MHC may serve as a significant way to decrease unintended pregnancies in the future.
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http://dx.doi.org/10.14423/SMJ.0000000000001204DOI Listing
February 2021

Reproductive intentions and corresponding use of safer conception methods and contraception among Ugandan HIV clients in serodiscordant relationships.

BMC Public Health 2021 01 19;21(1):156. Epub 2021 Jan 19.

Children's Mercy Research Institute, Children's Mercy Kansas City, Kansas City, USA.

Context: Among people living with HIV in Uganda, desires to have a child and unplanned pregnancies are both common, while utilization of safer conception methods (SCM) and modern contraceptives are low.

Methods: Three hundred eighty-nine HIV clients who reported considering childbearing with their uninfected partner enrolled in a safer conception counseling intervention trial in Uganda. Multiple regression analysis and baseline data were used to examine correlates of reproductive intentions and behaviors, including use of safer conception methods and contraception.

Results: Most (n = 313; 80.5%) reported that both they and their partner wanted to have a child now, which was associated with being married, in a longer relationship, not having a child with partner, greater SCM knowledge, lower internalized childbearing stigma, and higher perceived community stigma of childbearing. However, just 117 reported trying to conceive in the prior 6 months, which was associated with being female, not having a child with their partner, less decision-making control within the relationship, and greater perceived cultural acceptability of SCM. Among those who had tried to conceive in the past 6 months, 14 (11.9%) used SCM, which was associated with greater control in decision making. Of the 268 who were not trying to conceive, 69 (25.7%) were using a modern contraceptive, which was associated with being in a shorter relationship, less control over decision-making, more positive attitudes towards contraception and lower depression.

Conclusion: Methods to promote reproductive goals are underused by HIV serodiscordant couples, and relationships characteristics and childbearing-related stigma appear to be most influential and thus targets for intervention.

Trial Registration: Clinicaltrials.gov, NCT03167879 ; date registered May 23, 2017.
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http://dx.doi.org/10.1186/s12889-021-10163-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7814634PMC
January 2021

Stigma toward small babies and their mothers in Ghana: A study of the experiences of postpartum women living with HIV.

PLoS One 2020 16;15(10):e0239310. Epub 2020 Oct 16.

Center for Learning and Childhood Development-Ghana, Accra, Ghana.

Infants born to HIV-infected mothers are more likely to be low birthweight (LBW) than other infants, a condition that is stigmatized in many settings worldwide, including sub-Saharan Africa. Few studies have characterized the social-cultural context and response to LBW stigma among mothers in sub-Saharan Africa or explored the views of women living with HIV (WLHIV) on the causes of LBW. We purposively sampled thirty postpartum WLHIV, who had given birth to either LBW or normal birthweight infants, from two tertiary hospitals in Accra, Ghana. Using semi-structured interviews, we explored women's understanding of the etiology of LBW, and their experiences of caring for a LBW infant. Interviews were analyzed using interpretive phenomenology. Mothers assessed their babies' smallness based on the baby's size, not hospital-recorded birthweight. Several participants explained that severe depression and a loss of appetite, linked to stigma following an HIV diagnosis during pregnancy, contributed to infants being born LBW. Women with small babies also experienced stigma due to the newborns' "undesirable" physical features and other people's unfamiliarity with their size. Consequently, mothers experienced blame, reluctance showing the baby to others, and social gossip. As a result of this stigma, women reported self-isolation and depressive symptoms. These experiences were layered on the burden of healthcare and infant feeding costs for LBW infants. LBW stigma appeared to attenuate with increased infant weight gain. A few of the women also did not breastfeed because they thought their baby's small size indicated pediatric HIV infection. Among WLHIV in urban areas in Ghana, mother and LBW infants may experience LBW-related stigma. A multi-component intervention that includes reducing LBW incidence, treating antenatal depression, providing psychosocial support after a LBW birth, and increasing LBW infants' weight gain are critically needed.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0239310PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7567350PMC
November 2020

Beyond clinical food prescriptions and mobile markets: parent views on the role of a healthcare institution in increasing healthy eating in food insecure families.

Nutr J 2020 09 9;19(1):94. Epub 2020 Sep 9.

Health Services and Health Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA.

Background: Children in food-insecure families face increased barriers to meeting recommendations for fruit and vegetable consumption. Hospitals and pediatric healthcare institutions have attempted to alleviate food-insecurity through various internal programs like food prescriptions, yet little evidence for these programs exist. Consistent with a patient-centered perspective, we sought to develop a comprehensive understanding of barriers to fruit and vegetable consumption and a parent-driven agenda for healthcare system action.

Methods: We conducted six qualitative focus group discussions (four in English, two in Spanish) with 29 parents and caregivers of patients who had screened positive for food-insecurity during visits to a large pediatric healthcare system in a midwestern U.S. city. Our iterative analysis process consisted of audio-recording, transcribing and coding discussions, aiming to produce a) a conceptual framework of barriers to fruit and vegetable consumption and b) a synthesis of participant programmatic suggestions for their healthcare system.

Results: Participants were 90% female, 38% Black/African American and 41% Hispanic/Latino. Barriers to fruit and vegetable consumption in their families fell into three intersecting themes: affordability, accessibility and desirability. Participant-generated intervention recommendations were multilevel, suggesting healthcare systems focus not only on clinic and community-based action, but also advocacy for broader policies that alleviate barriers to acquiring healthy foods.

Conclusion: Parents envision an expanded role for healthcare systems in ensuring their children benefit from a healthy diet. Findings offer critical insight on why clinic-driven programs aimed to address healthy eating may have failed and healthcare organizations may more effectively intervene by adopting a multilevel strategy.
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http://dx.doi.org/10.1186/s12937-020-00616-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7487727PMC
September 2020

Barriers to maternal retention in HIV care in Ghana: key differences during pregnancy and the postpartum period.

BMC Pregnancy Childbirth 2020 Jul 17;20(1):398. Epub 2020 Jul 17.

Center for Learning and Childhood Development-Ghana, AF, 3190, Adenta Flats, Accra, Ghana.

Background: Maternal retention in HIV care is lower for women in the postpartum period than during pregnancy, but the reasons are poorly understood. We examined key differences in barriers to retention in HIV care during and after pregnancy.

Methods: We conducted semi-structured, in-depth interviews with 30 postpartum women living with HIV. Participants were recruited from two tertiary facilities implementing Option B+ for prevention of mother-to-child HIV transmission in Accra, Ghana. We collected data from mothers who had disengaged from HIV care and those who were still engaged in care. The interviews were analyzed using principles adapted from grounded theory.

Results: Participants' experiences and narratives showed that retention in HIV care was more challenging during the postpartum period than during pregnancy. Poor maternal physical health (from birth complications and cesarean section), socio-cultural factors (norms about newborn health and pregnancy), and economic difficulties linked to childbirth (such as unemployment, under-employment, and debt) made the costs of retention in HIV care more economically and socially expensive in the postpartum period than during pregnancy. Some participants also shared that transportation costs and resulting dependence on a partner to pay increased during the postpartum period because of a strong shift in maternal preference for private modes of transportation due to HIV stigma and the desire to protect the newborn. These factors played a larger role in the postpartum period than during pregnancy and created a significant barrier to retention. A conceptual model of how these factors interrelate, the synergy between them, and how they affect retention in the postpartum period is presented.

Conclusions: In Ghana, lower retention in HIV care in the postpartum period compared to in pregnancy may be primarily driven by social, economic, and newborn health factors. Multifaceted economic-based and stigma-reduction interventions are needed to increase retention in maternal HIV care after childbirth.
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http://dx.doi.org/10.1186/s12884-020-03067-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7366890PMC
July 2020

Advocating for Children During the COVID-19 School Closures.

Pediatrics 2020 09 17;146(3). Epub 2020 Jun 17.

Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.

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http://dx.doi.org/10.1542/peds.2020-1440DOI Listing
September 2020

Reductions in Parent Interest in Receiving Antibiotics following a 90-Second Video Intervention in Outpatient Pediatric Clinics.

J Pediatr 2020 10 15;225:138-145.e1. Epub 2020 Jun 15.

University of Missouri - Kansas City School of Medicine, Kansas City, MO; Pediatric Infectious Diseases, Children's Mercy, Kansas City, MO.

Objectives: To assess the impact of a 90-second animated video on parents' interest in receiving an antibiotic for their child.

Study Design: This pre-post test study enrolled English and Spanish speaking parents (n = 1051) of children ages 1-5 years presenting with acute respiratory tract infection symptoms. Before meeting with their provider, parents rated their interest in receiving an antibiotic for their child, answered 6 true/false antibiotic knowledge questions, viewed the video, and then rated their antibiotic interest again. Parents rated their interest in receiving an antibiotic using a visual analogue scale ranging from 0 to 100, with 0 being "I definitely do not want an antibiotic," 50 "Neutral," and 100 "I absolutely want an antibiotic."

Results: Parents were 84% female, with a mean age of 32 ± 6.0, 26.0% had a high school education or less, 15% were black, and 19% were Hispanic. After watching the video, parents' average antibiotic interest ratings decreased by 10 points (mean, 57.0 ± 20 to M ± 21; P < .0001). Among parents with the highest initial antibiotic interest ratings (≥60), even greater decreases were observed (83.0 ± 12.0 to 63.4 ± 22; P < .0001) with more than one-half (52%) rating their interest in the low or neutral ranges after watching the video.

Conclusions: A 90-second video can decrease parents' interest in receiving antibiotics, especially among those with higher baseline interest. This scalable intervention could be used in a variety of settings to reduce parents' interest in receiving antibiotics.

Trial Registration: ClinicalTrials.gov: NCT03037112.
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http://dx.doi.org/10.1016/j.jpeds.2020.06.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529942PMC
October 2020

Expanding Contraception Access for Women With Opioid-Use Disorder: A Qualitative Study of Opportunities and Challenges.

Am J Health Promot 2020 11 29;34(8):909-918. Epub 2020 May 29.

Department of Pediatric, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA.

Purpose: As almost nine in ten pregnancies among women with opioid use disorder (OUD) are unintended, expanding access to contraception is an underutilized but potentially effective strategy in increasing reproductive agency and reducing the overall burden of neonatal abstinence syndrome. We aimed to identify where and how contraceptive services could be integrated into existing points-of-contact for women with OUD.

Approach: In-depth qualitative interviews.

Setting: Three diverse catchment areas in Missouri.

Participants: Women with OUD (n = 15) and professional stakeholders (n = 16) representing five types of existing OUD service points: syringe exchange programs, recovery support programs, substance use treatment programs, emergency departments, and Federally Qualified Health Centers.

Method: Interviews were audio-recorded, transcribed, and thematically coded using Dedoose software.

Results: Six themes emerged as essential components for integrating contraceptive services into existing points-of-contact for women with OUD: (1) reach women with unmet need; (2) provide free or affordable contraception; (3) maximize service accessibility; (4) provide patient-centered care; (5) employ willing, qualified contraceptive providers; and (6) utilize peer educators. Participants affirmed the overall potential benefit of contraceptive service integration and illuminated various opportunities and challenges relevant to each type of existing service point.

Conclusion: As health promotion initiatives look to increase access to contraception among women with OUD, these six' participant-identified components offer essential guidance in selecting advantageous points-of-contact and addressing remaining gaps in services.
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http://dx.doi.org/10.1177/0890117120927327DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577934PMC
November 2020

"It was my obligation as mother": 18-Month completion of Early Infant Diagnosis as identity control for mothers living with HIV in Kenya.

Soc Sci Med 2020 Feb 27;250:112866. Epub 2020 Feb 27.

University of Kansas Medical Center, Department of Family Medicine, Kansas City, KS, USA.

Rationale: Early Infant Diagnosis (EID) is critical to timely identification of HIV and rapid treatment initiation for infants found to be infected. Completing the EID cascade involves a series of age-specific tests between birth and 18 months and can be challenging for mother- infant pairs in low-resource settings. Even prior to recent increases in Kenya's testing recommendations, approximately 22% of mother-infant pairs enrolled in EID were lost to follow-up. As EID cascades become increasingly complex, identifying strategies to maximize retention becomes even more essential. Despite ongoing health system improvements, we still lack a framework for understanding the individual-level, psychosocial processes underlying EID completion-insight that could be essential for shaping strategies to support patients and close gaps in retention.

Objective: Our objective was to explain individual-level processes that lead to EID completion among mothers who successfully completed the EID cascade.

Methods: Using qualitative methods informed by grounded theory, we conducted 65 interviews with Kenyan mothers who completed EID.

Results: We identified three themes related to completion: (1) Negative motivation, from the consequences of infant infection, fear of postnatal transmission, and burden of maternal failure; (2) Positive motivation, from achieving a final goal, responding to provider support, and maximizing infant health; and (3) Overcoming challenges, through resolve/resiliency, planning/privatizing and rejecting stigma/leveraging support.

Conclusion: Overall, the EID cascade served as a framing process for women to secure an identity as a good mother. Successful EID completion was the product of a strong motivational foundation channeled into strategies to surmount persistent challenges. Participant accounts of overcoming challenges highlight their resiliency as well as the outstanding need to address financial, logistical, and social barriers to care. Future EID programs may capitalize on these findings by affirming patients' quest for identity control, leveraging positive motivators, and expanding peer support structures to help mothers feel connected throughout the cascade.
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http://dx.doi.org/10.1016/j.socscimed.2020.112866DOI Listing
February 2020

Adapting the Diabetes Prevention Program for low- and middle-income countries: preliminary implementation findings from lifestyle Africa.

Transl Behav Med 2020 02;10(1):46-54

Center for Children's Healthy Lifestyles and Nutrition, Children's Mercy Kansas City, Kansas City, MO, USA.

Rates of cardiovascular disease and diabetes are rising in low- and middle-income countries (LMIC), but there is a dearth of research devoted to developing and evaluating chronic disease interventions in these settings, particularly in Africa. Lifestyle Africa is a novel, culturally adapted version of the Diabetes Prevention Program (DPP) being evaluated in an ongoing community-based cluster-randomized trial in an underresourced urban community in South Africa. The purpose of this study is to describe the adaptations and adaptation process used to develop the program and to report preliminary implementation findings from the first wave of groups (n = 11; 200 individuals) who participated in the intervention. The RE-AIM model and community advisory boards guided the adaptation process. The program was designed to be delivered by community health workers (CHWs) through video-assisted sessions and supplemented with text messages. Participants in the trial were overweight and obese members of existing chronic disease "support groups" served via CHWs. Implementation outcomes included completion of sessions, session attendance, fidelity of session delivery, and participant satisfaction. Results indicated that 10/11 intervention groups completed all 17 core sessions. Average attendance across all sessions and groups was 54% and the percentage who attended at least 75% of sessions across all groups was 35%. Fidelity monitoring indicated a mean of 84% of all required procedures were completed while overall communication skills were rated as "good" to "excellent". These preliminary results support the feasibility of culturally adapting the DPP for delivery by CHWs in underresourced settings in LMIC.
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http://dx.doi.org/10.1093/tbm/ibz187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7020390PMC
February 2020

Adapting the Diabetes Prevention Program for low and middle-income countries: protocol for a cluster randomised trial to evaluate 'Lifestyle Africa'.

BMJ Open 2019 11 11;9(11):e031400. Epub 2019 Nov 11.

Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA.

Introduction: Low and middle-income countries like South Africa are experiencing major increases in burden of non-communicable diseases such as diabetes and cardiovascular conditions. However, evidence-based interventions to address behavioural factors related to these diseases are lacking. Our study aims to adapt the CDC's National Diabetes Prevention Program (DPP) within the context of an under-resourced urban community in Cape Town, South Africa.

Methods/analysis: The new intervention () consists of 17 weekly sessions delivered by trained community health workers (CHWs). In addition to educational and cultural adaptations of DPP content, the programme adds novel components of text messaging and CHW training in Motivational Interviewing. We will recruit overweight and obese participants (body mass index ≥25 kg/m) who are members of 28 existing community health clubs served by CHWs. In a 2-year cluster randomised control trial, clubs will be randomly allocated to receive the intervention or usual care. After year 1, usual care participants will also receive the intervention and both groups will be followed for another year. The primary outcome analysis will compare percentage of baseline weight loss at year 1. Secondary outcomes will include diabetes and cardiovascular risk indicators (blood pressure, haemoglobin A1C, lipids), changes in self-reported medication use, diet (fat and fruit and vegetable intake), physical activity and health-related quality of life. We will also assess potential psychosocial mediators/moderators as well as cost-effectiveness of the programme.

Ethics/dissemination: Ethical approval was obtained from the University of Cape Town and Children's Mercy. Results will be submitted for publication in peer-reviewed journals and training curricula will be disseminated to local stakeholders.

Trial Registration Number: NCT03342274.
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http://dx.doi.org/10.1136/bmjopen-2019-031400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858109PMC
November 2019

"They Merely Prescribe and I Merely Swallow": Perceptions of Antenatal Pharmaceuticals and Nutritional Supplements Among Pregnant Women in Bamako, Mali.

Matern Child Health J 2020 Jan;24(1):110-120

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA.

Objectives: New international guidelines for antenatal care (ANC) will likely result in an increase in nutritional supplements and preventative medications for pregnant women in low and middle-income countries. Our objective was to understand how pregnant women in Mali perceive and experience multi-drug regimens in ANC in order to reveal factors that may influence uptake and adherence.

Methods: We conducted 29 semi-structured interviews and three focus groups with 21 pregnant women in two urban ANC sites in Bamako, Mali. Interviews focused on perception of purpose of ANC pharmaceuticals (particularly iron supplements, sulfadoxine-pyrimethamine as intermittent prevention of malaria and antiretroviral therapy for HIV), beliefs regarding efficacy and risk, and understanding of dosage and regimen. Transcripts were inductively coded and analyzed using the 'Framework' method.

Results: Participant descriptions of medication purpose, understanding of dosing, and beliefs about risks and efficacy varied widely, revealing that many pregnant women lack complete information about their medications. While some were burdened by side effects or complex regimens, women generally held favorable attitudes toward ANC medications. Responses suggest major barriers to adherence lie in the health system, namely insufficient patient-provider communication and inconsistent prescribing practices.

Conclusions For Practice: National health programs looking to improve maternal and child health with ANC pharmaceuticals need to place greater attention on patient counseling and consistent implementation of administration guidelines. Communication that positions pharmaceuticals as beneficial to mother and child, while presenting understandable information about purpose, dosing and potential side effects can promote uptake of multi-drug regimens and ANC services in general.
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http://dx.doi.org/10.1007/s10995-019-02808-2DOI Listing
January 2020

Rates and Predictors of HIV-Exposed Infants Lost to Follow-Up During Early Infant Diagnosis Services in Kenya.

AIDS Patient Care STDS 2019 08;33(8):346-353

5Department of Family Medicine and University of Kansas Medical Center, Kansas City, Missouri.

Early infant diagnosis (EID) involves age-specific tracking and testing of HIV-exposed infants during the first 18 months of life and rapid initiation of life-saving treatment for those infected. In Kenya, pre-2013 data estimate EID lost to follow-up (LTFU) at 39-65%, yet no study has documented LTFU rates and predictors throughout the EID cascade since Option B+ fundamentally changed services by placing all HIV-positive expectant mothers on lifelong treatment. Using an explanatory mixed-method design, we assessed LTFU rates and predictors among 870 mother-infant dyads enrolled in EID in six urban/peri-urban Kenyan government hospitals. Mothers completed baseline surveys, and dyads were tracked through EID. We selected 12 baseline variables and modeled odds of LTFU at 9 and 18 months using mixed logistic regression. Qualitative interviews were conducted with 61 mothers to assess barriers and facilitators to completing EID. Thematically coded transcripts were used to interpret quantitative predictors of LTFU. By the 18-month test, 145 dyads (22%) were LTFU, with three-quarters of LTFU occurring between 9- and 18-month tests. Odds of LTFU at 18 months decreased by 10% for each additional year of maternal age and by 66% with HIV status disclosure. Qualitative data revealed how disclosure facilitated essential social support for EID completion and how older mothers attributed maturity and life experience to successful engagement in care. Findings suggest LTFU rates in Kenya have declined, but gaps remain in ensuring universal coverage. Efforts to improve retention should focus on increasing support for younger mothers and those who have not disclosed their HIV status.
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http://dx.doi.org/10.1089/apc.2019.0050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6661912PMC
August 2019

eHealth Interventions for Early Infant Diagnosis: Mothers' Satisfaction with the HIV Infant Tracking System in Kenya.

AIDS Behav 2019 Nov;23(11):3093-3102

Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA.

The HIV Infant Tracking System (HITSystem) is an eHealth intervention to improve early infant diagnosis (EID) through alerts to providers and text messages to mothers. This study explored mothers' experiences receiving standard and HITSystem-enhanced EID services to assess perceived intervention benefits, acceptability, and opportunities for improvement. This qualitative study was embedded within a cluster-randomized control trial to evaluate the HITSystem at six Kenyan government hospitals (3 intervention, 3 control). We conducted semi-structured interviews with 137 mothers attending EID follow-up visits. Compared to control sites, participants at HITSystem sites described enhanced EID quality; HITSystem-generated texts informed them of result availability and retesting needs, provided cues-to-action for clinic attendance, and engendered opportunities for patient support. They described improved EID efficiency through shorter waiting periods for results and fewer hospital visits. Participants reported high satisfaction with EID and acceptability of text messages; however, modifications to ensure text delivery, increase repeat testing reminders, include low literacy content options, and provide encouraging messages were suggested. These user experience data suggest improvements in EID at HITSystem sites when compared with control sites.
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http://dx.doi.org/10.1007/s10461-019-02579-5DOI Listing
November 2019

Measuring shared decision-making in the pediatric outpatient setting: Psychometric performance of the SDM-Q-9 and CollaboRATE among English and Spanish speaking parents in the US Midwest.

Patient Educ Couns 2019 04 23;102(4):742-748. Epub 2018 Oct 23.

Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, USA; University of Missouri - Kansas City School of Medicine, Kansas City, USA; University of Missouri - Kansas City School of Pharmacy, Kansas City, USA.

Objective: Shared decision-making (SDM) measures have never been assessed for validity and feasibility in pediatric outpatient settings. We compared psychometric performance of parent adaptations of a well-established measure (SDM-Q-9) to a newer measure focusing on provider effort in facilitating SDM (CollaboRATE) in two clinics.

Methods: English (n = 955) and Spanish (n = 58) speaking parents of children ages 1-5 years with symptoms of acute respiratory tract infections (ARTI) completed post-visit SDM-Q-9, CollaboRATE, satisfaction items (visit, provider communication, and study participation), and qualitative feedback.

Results: Parents felt CollaboRATE was more comprehensible and relevant than SDM-Q-9, which refers to decision-making actions difficult to define in ARTI visits. Among English-speakers, both measures showed high internal consistency (α = 0.91, α = 0.97). SDM-Q-9 reliability was strong (split-half, r = 0.83) and CollaboRATE weak-to-moderate (two-week test-retest, ρ = 0.41-0.66). Convergent validity with communication and visit satisfaction was poor for SDM-Q-9 (r=0.38, r=0.34) but higher for CollaboRATE (r=0.59, r = 0.52). Both showed divergent validity with study participation satisfaction (r=0.08, r=0.13). Spanish versions demonstrated similar results.

Conclusions: Parent preference and correlations with satisfaction support CollaboRATE over SDM-Q-9, however psychometrics were borderline acceptable.

Practice Implications: Tools like CollaboRATE that focus on provider effort appear more appropriate for routine pediatric visits where SDM outcomes may be difficult to identify, yet additional validation research is needed.
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http://dx.doi.org/10.1016/j.pec.2018.10.015DOI Listing
April 2019

Implementing eHealth Technology to Address Gaps in Early Infant Diagnosis Services: Qualitative Assessment of Kenyan Provider Experiences.

JMIR Mhealth Uhealth 2018 Aug 22;6(8):e169. Epub 2018 Aug 22.

Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States.

Background: Literature suggests that electronic health (eHealth) interventions can improve the efficiency and accuracy of health service delivery and improve health outcomes and are generally well received by patients; however, there are limited data on provider experiences using eHealth interventions in resource-limited settings. The HIV Infant Tracking System (HITSystem) is an eHealth intervention designed to improve early infant diagnosis (EID) outcomes among HIV-exposed infants.

Objective: We aimed to compare provider experiences with standard EID and HITSystem implementation at 6 Kenyan hospitals and 3 laboratories. The objective of this study was to better understand provider experiences implementing and using the HITSystem in order to assess facilitators and barriers that may impact adoption and sustainability of this eHealth intervention.

Methods: As part of a randomized controlled trial to evaluate the HITSystem, we conducted semistructured interviews with 17 EID providers at participating intervention and control hospitals and laboratories.

Results: Providers emphasized the perceived usefulness of the HITSystem, including improved efficiency in sample tracking and patient follow-up, strengthened communication networks among key stakeholders, and improved capacity to meet patient needs compared to standard EID. These advantages were realized from an intervention that providers saw as easy to use and largely compatible with workflow. However, supply stock outs and patient psychosocial factors (including fear of HIV status disclosure and poverty) provided ongoing challenges to EID service provision. Furthermore, slow or sporadic internet access and heavy workload prevented real-time HITSystem data entry for some clinicians.

Conclusions: Provider experiences with the HITSystem indicate that the usefulness of the HITSystem, along with the ease with which it is able to be incorporated into hospital workflows, contributes to its sustained adoption and use in Kenyan hospitals. To maximize implementation success, care should be taken in intervention design and implementation to ensure that end users see clear advantages to using the technology and to account for variations in workflows, patient populations, and resource levels by allowing flexibility to suit user needs.

Trial Registration: ClinicalTrials.gov NCT02072603; https://clinicaltrials.gov/ct2/show/NCT02072603 (Archived by WebCite at http://www.webcitation.org/71NgMCrAm).
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http://dx.doi.org/10.2196/mhealth.9725DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6125609PMC
August 2018

Study protocol of "Our Choice": a randomized controlled trial of the integration of safer conception counseling to transform HIV family planning services in Uganda.

Implement Sci 2018 08 14;13(1):110. Epub 2018 Aug 14.

RAND Corporation, Santa Monica, CA, USA.

Background: About 40% of HIV-positive women in sub-Saharan Africa become pregnant post-diagnosis. Despite about half of their pregnancies being planned, safer conception methods (SCM) are underutilized among serodiscordant couples, partially due to the fact that safer conception counseling (SCC) has not been integrated into routine HIV family planning (FP) services.

Methods: Our Choice is a comprehensive FP intervention that promotes unbiased childbearing consultations to ensure clients receive SCC or contraception services to achieve their desired reproductive goals. The intervention is theoretically grounded and has demonstrated preliminarily feasibility and acceptance through pilot testing. This three-arm cluster randomized controlled trial compares two implementation strategies for integrating Our Choice into routine FP services vs. usual care. Six sites in Uganda will be randomized to receive either (1) Our Choice intervention with enhanced training and supervision provided by study staff (SCC1), (2) Our Choice intervention implemented by the Ministry of Health's standard approach to disseminating new services (SCC2), or (3) existing FP services (usual care). Our Choice and usual care FP services will be implemented simultaneously over a 30-month period. Sixty clients in serodiscordant relationships who express childbearing desires will be enrolled by a study coordinator at each site (n = 360) and followed for 12 months or post-pregnancy (once, if applicable). Analysis will compare intervention arms (SCC1 and SCC2) to usual care and then to each other (SCC1 vs. SCC2) on the primary outcome of correct use of either SCM (if trying to conceive) or dual contraception (if pregnancy is not desired). Secondary outcomes (i.e., pregnancy, use of prevention of mother-to-child transmission services, condom use, and partner seroconversion) and cost-effectiveness will also be examined.

Discussion: Findings will provide critical information about the success of implementation models of varying intensity for integrating SCC into FP, thereby informing policy and resource allocation within and beyond Uganda.

Trial Registration: NCT03167879 ClinicalTrials.gov, Registered 30 May, 2017.
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http://dx.doi.org/10.1186/s13012-018-0793-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6092849PMC
August 2018

Protocol for a randomised trial of higher versus lower intensity patient-provider communication interventions to reduce antibiotic misuse in two paediatric ambulatory clinics in the USA.

BMJ Open 2018 05 9;8(5):e020981. Epub 2018 May 9.

Pediatric Infectious Disease, St. Louis Children's Hospital, St. Louis, Missouri, USA.

Introduction: Children with acute respiratory tract infections (ARTIs) are prescribed up to 11.4 million unnecessary antibiotic prescriptions annually. Inadequate parent-provider communication is a chief contributor, yet efforts to reduce overprescribing have only indirectly targeted communication or been impractical. This paper describes our multisite, parallel group, cluster randomised trial comparing two feasible interventions for enhancing parent-provider communication on the rate of inappropriate antibiotic prescribing (primary outcome) and revisits, adverse drug reactions and parent-rated quality of shared decision-making, parent-provider communication and visit satisfaction (secondary outcomes).

Methods/analysis: We will attempt to recruit all eligible paediatricians and nurse practitioners (currently 47) at an academic children's hospital and a private practice. Using a 1:1 randomisation, providers will be assigned to a higher intensity education and communication skills or lower intensity education-only intervention and trained accordingly. We will recruit 1600 eligible parent-child dyads. Parents of children ages 1-5 years who present with ARTI symptoms will be managed by providers trained in either the higher or lower intensity intervention. Before their consultation, all parents will complete a baseline survey and view a 90 s gain-framed antibiotic educational video. Parent-child dyads consulting with providers trained in the higher intensity intervention will, in addition, receive a gain-framed antibiotic educational brochure promoting cautious use of antibiotics and rate their interest in receiving an antibiotic which will be shared with their provider before the visit. All parents will complete a postconsultation survey and a 2-week follow-up phone survey. Due to the two-stage nested design (parents nested within providers and clinics), we will employ generalised linear mixed-effect regression models.

Ethics/dissemination: Ethical approval was obtained from the Children's Mercy Hospital Pediatric Institutional Review Board (#16060466). Results will be submitted for publication in peer-reviewed journals.

Trial Registration Number: NCT03037112; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2017-020981DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5942422PMC
May 2018

Postponing Childbearing and Fertility Preservation in Young Professional Women.

South Med J 2018 04;111(4):187-191

From the Division of Reproductive Endocrinology and Infertility, Department of OB/GYN, University of Cincinnati Medical Center, Cincinnati, Ohio, Reproductive Medicine Associates of Connecticut, Norwalk, Connecticut, Christ Hospital, Cincinnati, Ohio, Colorado Center for Reproductive Medicine Minneapolis, Minneapolis, Minnesota, and the University of Buffalo, Buffalo, New York.

Objectives: To evaluate young women's awareness of ovarian reserve testing and oocyte cryopreservation (OC) and assess how testing ovarian reserve may affect the desire for fertility preservation.

Methods: Three questionnaire-based observational studies were conducted among female students/young professionals 20 years of age and older. The third survey was completed after participants were offered anti-Mullerian hormone (AMH) testing. The main outcomes measured included awareness that OC is available, interest in pursuing fertility preservation, and whether interest would change based on knowledge of declining fertility.

Results: The first tier of the study included a survey of a total of 337 women. The majority of female subjects were aware of OC (92.1%). Approximately 38.5% of the women responded that they would consider OC for future fertility purposes. This percentage increased to 60.3% if one was aware her fertility was declining. The second tier of the study included 42 resident/fellow physicians who were offered AMH testing. A survey was completed before and after testing was completed. Approximately 12% of participants stated that their AMH level altered their anticipated age of childbearing, whereas 24% would consider cryopreservation based on their results. The most common concern regarding OC was the cost.

Conclusions: Women should be counseled regarding reproductive aging and options for fertility preservation. Offering ovarian reserve testing and making OC more affordable may increase the number of women who undergo elective OC.
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http://dx.doi.org/10.14423/SMJ.0000000000000789DOI Listing
April 2018

Changes in Providers' Self-Efficacy and Intentions to Provide Safer Conception Counseling Over 24 Months.

AIDS Behav 2018 Sep;22(9):2895-2905

Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda.

High rates of fertility desires, childbearing and serodiscordant partnerships among people living with HIV (PLHIV) in Uganda underscore the need to promote use of safer conception methods (SCM). Effective SCM exist but few PLHIV benefit from provider-led safer conception counseling (SCC) and comprehensive national SCC guidelines are still lacking. Providers' self-efficacy, intentions and attitudes for SCC impact provision and should inform development of services, but there are no longitudinal studies that assess these important constructs. This study reports on changes in providers' knowledge, attitudes, motivation and confidence to provide SCC among a 24-month observational cohort of Ugandan HIV providers. Compared to baseline, providers evidenced increased awareness of SCM, perceived greater value in providing SCC, saw all SCM but sperm washing as likely to be acceptable to clients, reported consistently high interest in and peer support for providing SCC, and perceived fewer barriers at the 24-month follow-up. Providers' intentions for providing SCC stayed consistently high for all SCM except manual self-insemination which decreased at 24 months. Self-efficacy for providing SCC increased from baseline with the greatest improvement in providers' confidence in advising serodiscordant couples where the man is HIV-infected. Providers consistently cite the lack of established guidelines, training, and their own reluctance to broach the issue with clients as significant barriers to providing SCC. Despite providers being more interested and open to providing SCC than ever, integration of SCC into standard HIV services has not happened. Concerted efforts are needed to address remaining barriers by establishing national SCC guidelines and implementing quality provider training.
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http://dx.doi.org/10.1007/s10461-018-2049-xDOI Listing
September 2018

Patient-centred attitudes among medical students in Mali, West Africa: a cross-sectional study.

BMJ Open 2018 01 23;8(1):e019224. Epub 2018 Jan 23.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

Background/objective: Patient-centred attitudes have been shown to decline during medical training in high-income countries, yet little is known about attitudes among West African medical students. We sought to measure student attitudes towards patient-centredness and examine validity of the 18-item Patient-Practitioner Orientation Scale (PPOS) in this context.

Participants/setting: 430 medical students in years 1, 3, 5 and 6 of a 6-year medical training programme in Bamako, Mali.

Design: We conducted a cross-sectional survey, compared the proportion of students who agreed with each PPOS item by gender and academic year, and calculated composite PPOS scores. To examine psychometrics of the PPOS and its two subscales ('sharing' and 'caring'), we calculated internal consistency (Cronbach's alpha) and performed confirmatory and exploratory factor analyses (CFA and EFA).

Results: In seven of the nine 'sharing' items, the majority of students held attitudes favouring a provider-dominant style. For five of the nine 'caring' items, the majority of student responded consistently with patient-centred attitudes, while in the other four, responses indicated a disease-centred orientation. In eight items, a greater proportion of fifth/sixth year students held patient-centred attitudes as compared with first year students; there were few gender differences. Average PPOS scores indicated students were moderately patient-centred, with more favourable attitudes towards the 'caring' aspect than 'sharing'. Internal consistency of the PPOS was inadequate for the full scale (α=0.58) and subscales ('sharing' α=0.37; 'caring' α=0.48). CFA did not support the original PPOS factors and EFA did not identify an improved structure.

Conclusions: West African medical students training in Bamako are moderately patient-centred and do not show the same declines in patient-centred attitudes in higher academic years as seen in other settings. Medical students may benefit from training in shared power skills and in attending to patient lifestyle factors. Locally validated tools are needed to guide West African medical schools in fostering patient-centredness among students.
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http://dx.doi.org/10.1136/bmjopen-2017-019224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786142PMC
January 2018

The Role of Patient-Provider Communication in Engagement and Re-engagement in HIV Treatment in Bamako, Mali: A Qualitative Study.

J Health Commun 2018 27;23(2):129-143. Epub 2017 Dec 27.

a Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA.

Mounting evidence in sub-Saharan Africa suggests poor patient-provider communication (PPC) negatively impacts patient engagement (retention in care and adherence to medication) in antiretroviral therapy (ART) programs. In Bamako, Mali, where 36% of ART patients are lost to follow-up within 12 months of initiating treatment, we aimed to define features of positive PPC according to patient values and explore the mechanisms by which these features may sustain engagement and re-engagement according to patient and provider experiences. We conducted 33 in-depth interviews and 7 focus groups with 69 patients and 17 providers in five ART clinics. Regarding sustaining engagement, participants highlighted "establishing rapport" as a foundational feature of effective PPC, but also described how "responding to emotional needs", "eliciting patient conflicts and perspective" and "partnering to mitigate conflicts" functioned to address barriers to engagement and increase connectedness to care. Patients who had disengaged felt that "communicating reacceptance" may have prompted them re-engage sooner and that tailored "partnering to mitigate conflicts" would be more effective in sustaining re-engagement than the standard adherence education providers typically offer. Optimizing provider skills related to these key PPC features may help maximize ART patient engagement, ultimately improving health outcomes and decreasing HIV transmission in sub-Saharan Africa.
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http://dx.doi.org/10.1080/10810730.2017.1417513DOI Listing
October 2019
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