Allison P Squires

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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.

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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.

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BACKGROUND: Preparing and deploying a primary care workforce ready to care for the aging global population requires increasing efficiency in graduate level health professions education while ensuring competence in interprofessional practice. Training programs need to meet population health needs while also addressing the challenges of coordinating training schedules of diverse professionals, many of whom are practicing professionals. This study reports on the first year program evaluation of a unique nurse practitioner and physician training program focused on improving geriatric interprofessional care in the primary care setting. The program intervention included a week long joint educational program with physicians and nurse practitioners, online learning modules, and follow up learning exercises. Faculty designing the program included experienced geriatric nurse practitioners, primary care graduate level physician educators, an instructional technologist, and a behavioral scientist. METHODS: Evaluation data for the study drew from multiple sources including pre and post intervention focus group interviews with 10 student participants (8 MD, 2 NP), performance reports from the online learning modules, surveys about perceptions about interprofessional teamwork and practices, course evaluations, and faculty reflections. We conducted general descriptive analyses appropriate for the data type. The small sample size limited statistical comparison for significant differences between respondents. RESULTS: In the interviews participants emphasized how program training sites negatively limit the ability to deliver quality geriatric primary care and apply classroom content in the "real world". Participants also reported feeling uncomfortable providing feedback about other professions when in the same room. Issues around leadership also emerged as power dynamics between professions influenced perceived roles and responsibilities. Perceptions of quality of interprofessional collaboration at the current site of clinical practice remained nearly the same before (6.56/10) and after (6.2/10) the intervention. Perceptions of team leadership and serving as an equal contributor trended upward after the intervention. Overall perceptions of interprofessional collaboration on existing teams at their training sites, however, trended largely downward. Participants, in short answer questions, felt least comfortable addressing geriatric care issues related to patient safety, end of life care situations, communication, and work allocation. Synthesizing all the results suggest that this type of program may be effective in improving geriatric content overall but in an interprofessional education context, may sensitize learners to broader issues around geriatric primary care delivery, such as appropriate use of different roles on the healthcare team. CONCLUSIONS: Rich data from this first year of a 3 year study is informing the development of interprofessional geriatric primary care training programs, which could help health professions schools reinforce and address interprofessional care delivery issues that may predictably arise after this type of intensive educational intervention. It is also noteworthy that the role of the training site in reinforcing or undermining appropriate delivery of geriatric specific care cannot be ignored.