Allison P Squires

Abstract

~

Abstract

Background: Obesity affects 37 % of patients at Veterans Health Administration (VHA) medical centers. The VHA offers an intensive weight management program (MOVE!) but less than 10 % of eligible patients ever attend. However, VHA patients see their primary care provider about 3.6 times per year, supporting the development of primary care-based weight management interventions. To address gaps in the literature regarding Veterans' experiences with weight management and determine whether and how to develop a primary care-based weight management intervention to both improve obesity counseling and increase attendance to MOVE!, we conducted a qualitative study to assess: 1) Veterans' personal experiences with healthy weight-related behavior change (including barriers and facilitators to behavior change and experiences with primary care providers, staff, and the MOVE! program), and 2) potential new approaches to improve weight management within primary care at the VHA including goal setting and technology. Methods: Overweight/obese VHA patients (aged 18-75, BMI greater than 30 or greater than 25 with at least 1 co-morbidity) were recruited for focus group sessions stratified by gender, MOVE! referral, and attendance. Each session was facilitated by a trained moderator, audio-recorded, and professionally transcribed. Using an iterative coding approach, two coders separately reviewed and coded transcripts, and met frequently to negotiate codes and synthesize emerging themes. (Continued on next page) Results: Of 161 eligible patients, 54 attended one of 6 focus groups (2 female, 4 male, 9-11 participants per session): 63 % were male, 46 % identified as African-American, 32 % White/Caucasian, 74 % were college-educated or higher, and 61 % reported having attended MOVE!. We identified two major themes: Impact of Military Service and Promotion and Sustainability of Healthy Behaviors. After service in a highly structured military environment, Veterans had difficulty maintaining weight on their own. They perceived physical activity as having more impact than diet, but chronic pain was a barrier. We identified individual/interpersonal-, community/environment-, and healthcare system-related factors affecting healthy behaviors. We also received input about Veteran's preferences and experiences with technology and setting health goals. Conclusions: Unique factors influence weight management in Veterans. Findings will inform development of a technology-assisted weight management intervention with tailored counseling and goal-setting within primary care at the VHA.

Abstract

Simulation in obstetrics and gynecology (OBGYN) training captures a range of interpersonal, cognitive, and technical skills. However, trainee perspectives on simulation-based assessment remain unexplored. After an observed structured clinical examination (OSCE) simulation hybrid exam, two focus groups of residents were conducted. Analysis grounded in a thematic coding guided the qualitative research process. Responses suggest a valuation of cognitive and technical skills over interpersonal skills. Realism was seen as critical and residents perceived the assessment as more valuable for the educator than the learner. Feedback was highly valued. Resident perspectives on this exam give insight into their perceptions of simulation-based assessment as well as their conceptions of their own learning through simulations.

Abstract

~

Abstract

~

Abstract

State and international entities can have profound effects on the development of a country's nursing profession. Through a global health governance lens, this paper explores the development of nursing in Brazil during the early twentieth century, and its intersections with national and international interests. Accordingly, we will show how state policies established an environment that fostered the institutionalization of nursing as a profession in Brazil and supported it as a means to increase the presence of females in nation building processes. The State focused on recruiting elite women for nursing, in part due to the Rockefeller Foundation's involvement in the country. Nurses who worked for Rockefeller came from well-educated classes within US society with specific ideas about who should be a nurse and the roles of nurses in a healthcare system. These women served as the primary vehicles for interacting with Brazilian health authorities responsible for health system development. Their early efforts did not, however, ensure a system capable of producing nursing human resources at a rate that, in present day Brazil, could meet the health needs of the country. Findings from this paper offer new avenues for historians to explore the early roots of professional nursing through a global health governance lens, improve the understanding of the intersection between international politics and professionalization, and highlight how these factors may impact nursing human resources production in the long term.

Abstract

Background: Obesity is highly prevalent among Veterans. In the United States, the Veterans Health Administration (VHA) offers a comprehensive weight management program called MOVE!. Yet, fewer than 10 % of eligible patients ever attend one MOVE! visit. The VHA has a patient-centered medical home (PCMH) model of primary care (PC) called Patient-Aligned Care Teams (PACT) at all Veterans Affairs (VA) Medical Centers. PACT teamlets conduct obesity screening, weight management counseling, and refer to MOVE!. As part of a needs assessment to improve delivery of weight management services, the purpose of this study was to assess PACT teamlet and MOVE! staff: 1) current attitudes and perceptions regarding obesity care; 2) obesity-related counseling practices 3) experiences with the MOVE! program; and 4) targets for interventions to improve implementation of obesity care in the PC setting. Methods: We recruited 25 PACT teamlet members from a single VA study site - 11 PC physicians, 5 registered nurses, 5 licensed practical nurses, 1 clerical assistant, and 3 MOVE! staff (2 dietitians, 1 psychologist) - for individual interviews using a combination of convenience and snowball sampling. Audio recorded interviews were professionally transcribed and iteratively coded by two independent reviewers. The analytic process was guided by discourse analysis in order to discover how the participants perceived and provided weight management care and what specific attitudes affected their practices, all as bounded within the organization. Results: Emerging themes included: 1) role perceptions, 2) anticipated outcomes of weight management counseling and programs, and 3) communication and information dissemination. Perceived role among PCPs was influenced by training, whereas personal experience with their own weight management impacted role perception among LPNs/RNs. Attitudes about whether or not they could impact patients' weight outcomes via counseling or referral to MOVE! varied. System-level communication about VHA priorities through electronic health records and time allocation influenced teams to prioritize referral to MOVE! over weight management counseling. Conclusion: We found a diversity of attitudes, and practices within PACT, and identified factors that can enhance the MOVE! program and inform interventions to improve weight management within primary care. Although findings are site-specific, many are supported in the literature and applicable to other VA and non-VA sites with PCMH models of care.

Abstract

~

Abstract

Background: New targets for global development emphasize poverty reduction with some perceiving these priorities as de-emphasizing healthcare investments even though health and poverty are inextricably linked. This study sought to examine the relationships between key country development indicators and physician and nurse-topopulation ratios in order to explore the potential impact poverty reduction investments could have on human resources for health production. Methods: Publicly available data from international databases that collect human resources for health, political system, economic, and population demographic data comprised the data for the 184 countries included in this cross-national comparative observational study. Selected variables have known influences on healthcare systems indicators. Data were from the most recent year available. Relationships between key variables were examined using descriptive and multiple regression techniques. Missing data were imputed using the ICE technique in STATA. Analyses were also replicated in R for added rigor. IRB approval for this study was obtained through New York University. Findings: Average education levels of the population were strongly and significantly correlated with the nurse/midwife (r = .60, p=0.000) and physician (r = .72, p=0.000) to population ratios. In regression models, average years of school in a country's population, emigration rates, beds per 1,000 population, and low income country statuses were consistently statistically significant predictor variables. Regression models found that the combination of variables explained 63% of the nurse/midwife-to-population ratio (pseudo R2=.627, p = .0000) and 73% of the physician-to-population ratio (pseudo R2 = .729, p = .0000). Interpretation: Poverty reduction priorities in the next decade appear to have the potential to indirectly facilitate the production of human resources for health. The education variable in the model and its consistent significance is the best illustrator of the potential long term effects of these investments. While the study was limited by the overall quality and availability of data, the stability of the model across various analytic strategies strengthens the rigor of the results. Thus, while poverty reduction initiatives may help future generations and long term economic development, policies and investments also need to strengthen present day production systems that support the operations of health systems vital to combating health conditions related to poverty.

Abstract

BACKGROUND: Obesity affects 36 % of patients in the Veterans Health Administration. The United States Preventive Services Task Force endorses the use of the 5As framework (Assess, Advise, Agree, Assist, Arrange) to deliver obesity counseling in primary care (PC). This study used qualitative methods to inform the development of a 5As-based weight management intervention to improve obesity care at Veterans Affairs (VA) Medical Centers. METHODS: We conducted a secondary analysis of 6 focus group sessions with Veteran patients and 25 interviews with key VA staff in PC (physicians, nurses, and MOVE! staff) in order to guide intervention development. We asked Veterans and staff to provide feedback on a proposed 5As intervention initially conceived based on prior work and a systematic review of the literature. This proposed intervention would use an online tool to deliver the 5As by assessing health behaviors and barriers (“assess”), providing tailored advice (“advise”), and helping patients set goals (“agree”). Members of the healthcare team would then discuss goals further, focusing on addressing barriers (“assist”) and providing follow-up/referral to more intensive support (“arrange”). Participants were also asked about their experiences with goal setting, weight management, and technology. Focus group and interview sessions were audio-recorded, professionally transcribed, and coded using a rigorous process previously described. To guide intervention development, transcription segments originally coded as “goal-setting,” “proposed intervention,” and/or “technology” were analyzed. The “proposed intervention” code had not been previously analyzed. RESULTS: Both Veterans and VA staff held positive views toward the use of goal setting for healthy behavior change and stressed the importance of social support in achieving goals. Veterans particularly felt the need for someone to hold them accountable for their goals and give them consistent feedback on their progress. VA staff felt that the goals needed to come directly from the patient and that the providers' role was to support the process. Veterans and staff reported mixed attitudes toward technology, acknowledging that some patients were unfamiliar with or distrusting of technology. When asked to give feedback about the proposed intervention, Veterans and staff liked that it would provide individualized counseling and support from the healthcare team to achieve goals. However, some Veterans did not believe a computer could generate individualized advice and did not want technology to replace human support. Most healthcare team members felt that time constraints would be a barrier to implementation and indicated that they could not spend more than 3-5 min on weight management. As a result of these findings, our revised intervention includes the use of a health coach to provide in-person support while using the online tool. The health coach will also provide initial counseling about weight loss and lifestyle goals to allow the healthcare team to focus their time on performing brief counseling to address barriers and endorse the goals. CONCLUSIONS: This study informed the development of a 5As intervention to improve the treatment of obesity in the PC setting. Usability testing of the online tool is currently ongoing, and pilot testing of the intervention will begin soon.