Qualitative study of opioid overdose education and naloxone access strategies in community health center primary care settings: opportunities for expanding access and saving lives

BACKGROUND: Naloxone, an opioid antagonist, offers a powerful tool for preventing opioid overdose deaths. Because studies have shown opioid overdose education and naloxone distribution (OEND) programs to be a safe, feasible, and effective intervention, several policymakers and public health agencies have advocated for broader access to this life-saving medication. Community health centers (CHCs) are a promising location for expanding naloxone access. This investigation examined the experience of CHC-based HIV primary care teams with a variety of overdose education and naloxone access (OENA) strategies in order to inform future dissemination efforts. METHODS: A mixed methods study was conducted with eight CHCs located in Massachusetts communities experiencing high opioid overdose fatality rates. Individual and group interviews with 29 clinic staff members; clinic and participant surveys; and document review were used to elucidate the OENA strategies. The Consolidated Framework for Implementation Research guided the data collection process and subsequent analysis, which revealed several factors supporting or hindering implementation of OENA activities in CHC primary care settings. RESULTS: Operating in a facilitative state policy environment, the CHCs utilized a mix of approaches to OENA: providing clinic-based services, issuing prescriptions, utilizing pharmacy standing orders, and making referrals to existing community-based OEND programs. With prescribers having limited time and competing priorities, nurses, health educators, and other staff played a prominent role in OENA. Pharmacies also served as important access points for patients and community residents. Several strategies were used to engage patients, including active outreach, partnerships with external organizations, and efforts to destigmatize substance use disorders. Clinic staff participation was enhanced through leadership support for harm reduction approaches, ongoing training, peer modeling, and information sharing. CONCLUSIONS: This study demonstrated that OENA can be integrated into CHC primary care services, adapted to the clinic context, and modified as needed. Successful implementation required a systems-level response, grounded in a team-based care model and a consideration of patient needs. The process for naloxone reimbursement needs to be determined to minimize CHC or patient barriers and ensure sustainability. Clinic training and technical assistance plans should be customized according to the staff members’ potential roles and their stage of readiness

Qualitative study of opioid overdose education and naloxone access strategies in community health center primary care settings: opportunities for expanding access and saving lives

BACKGROUND: Naloxone, an opioid antagonist, offers a powerful tool for preventing opioid overdose deaths. Because studies have shown opioid overdose education and naloxone distribution (OEND) programs to be a safe, feasible, and effective intervention, several policymakers and public health agencies have advocated for broader access to this life-saving medication. Community health centers (CHCs) are a promising location for expanding naloxone access. This investigation examined the experience of CHC-based HIV primary care teams with a variety of overdose education and naloxone access (OENA) strategies in order to inform future dissemination efforts. METHODS: A mixed methods study was conducted with eight CHCs located in Massachusetts communities experiencing high opioid overdose fatality rates. Individual and group interviews with 29 clinic staff members; clinic and participant surveys; and document review were used to elucidate the OENA strategies. The Consolidated Framework for Implementation Research guided the data collection process and subsequent analysis, which revealed several factors supporting or hindering implementation of OENA activities in CHC primary care settings. RESULTS: Operating in a facilitative state policy environment, the CHCs utilized a mix of approaches to OENA: providing clinic-based services, issuing prescriptions, utilizing pharmacy standing orders, and making referrals to existing community-based OEND programs. With prescribers having limited time and competing priorities, nurses, health educators, and other staff played a prominent role in OENA. Pharmacies also served as important access points for patients and community residents. Several strategies were used to engage patients, including active outreach, partnerships with external organizations, and efforts to destigmatize substance use disorders. Clinic staff participation was enhanced through leadership support for harm reduction approaches, ongoing training, peer modeling, and information sharing. CONCLUSIONS: This study demonstrated that OENA can be integrated into CHC primary care services, adapted to the clinic context, and modified as needed. Successful implementation required a systems-level response, grounded in a team-based care model and a consideration of patient needs. The process for naloxone reimbursement needs to be determined to minimize CHC or patient barriers and ensure sustainability. Clinic training and technical assistance plans should be customized according to the staff members’ potential roles and their stage of readiness

Chapter 11- Team-Based Learning Brings Academic Rigor, Collaboration, and Community to Online Learning

In early 2020, instructors were faced with a critical and immediate need to move education online in the face of the COVID-19 pandemic. The decision to discontinue face-to-face classes as a protection from the COVID-19 virus presented several questions and challenges, including the need to quickly develop online classes without adequate time to consider the effectiveness of different strategies. While online learning provides accessible and safe educational opportunities for students sheltering in place as a protection against the COVID-19 pandemic, faculty may question if online education provides the academic rigor, needed competencies, and student learning outcomes they hoped for in traditional campus classes

Culture, Caregiving, and Health: Exploring the Influence of Culture on Family Caregiver Experiences

Ethnic minorities are expected to experience a greater demand for family caregiving than non-Latino Whites due to their projected population growth. Although the consensus of researchers on caregiving and culture finds that the caregiving experience differs significantly among cultural/ethnic groups, the question remains as to how cultural values and norms influence the caregiver experiences. We conducted an interpretative, phenomenological qualitative analysis of focus group transcripts from four groups (African American, Asian American, Hispanic American, and European American) for cultural influences on caregiving. Data were collected in Nevada between December 7, 2009, and August 20, 2010. Thirty-five caregivers participated in this study. We found commonalities among all of the cultural/ethnic groups in their experiences of the difficulties of caregiving. However, there were some significant differences in the cultural values and norms that shaped the caregiving experience. We categorized these differences as: (a) cultural embeddedness of caregiving, (b) cultural determinants of caregiving responsibilities or taxonomy of caregiving, and (c) cultural values and norms underlying the decision to provide care. The significance of this study is that it highlights the culturally perceived mandate to provide care in the African, Asian, and Hispanic American cultures

Beyond Goldwater-Nichols

This report culminated almost two years of effort at CSIS, which began by developing an approach for both revisiting the Goldwater-Nichols Department of Defense Reorganization Act of 1986 and for addressing issues that were beyond the scope of that landmark legislation

Winter Habitat Quality but not Long- distance Dispersal Influences Apparent Reproductive Success in a Migratory Bird

Long- distance breeding and natal dispersal play central roles in many ecological and evolutionary processes, including gene flow, population dynamics, range expansion, and individual responses to fluctuating biotic and abiotic conditions. However, the relative contribution of long- distance dispersal to these processes depends on the ability of dispersing individuals to successfully reproduce in their new environment. Unfortunately, due to the difficulties associated with tracking dispersal in the field, relatively little is known about its reproductive consequences. Furthermore, because reproductive success is influenced by a variety of processes, disentangling the influence of each of these processes is critical to understanding the direct consequences of dispersal. In this study, we used stable hydrogen and carbon isotopes to estimate long- distance dispersal and winter territory quality in a migratory bird, the American Redstart (Setophaga ruticilla). We then applied Aster life-history models to quantify the strength of influence of these factors on apparent reproductive success. We found no evidence that male or female reproductive success was lower for long- distance dispersers relative to non- dispersing individuals. In contrast, carry- over effects from the winter season did influence male, but not female, reproductive success. Use of Aster models further revealed that for adult males, winter territory quality influenced the number of offspring produced whereas for yearling males, high- quality winter territories were associated with higher mating and nesting success. These results suggest that although long- distance natal and breeding dispersal carry no immediate reproductive cost for American Redstarts, reproductive success in this species may ultimately be limited by the quality of winter habitat

Evaluating the Interactive Effects of Seasonal Prescribed Fire and Grazing On Invasive Grass Abundance and Woody Brush Encroachment

Developing effective restoration techniques for encroached and invaded grasslands requires an understanding of two fundamental ecological processes: fire and grazing. Prescribed fire and grazing are suggested management techniques for preventing shrub encroachment and suppressing non-native species, especially in areas with functionally distinct native and exotic grasses. This study evaluates the effects on two encroached grasslands in South Africa and south Texas. In south Texas, native prairies are undergoing woody brush encroachment and exotic plant invasion concurrently. The exotic C4 grass species (Bothriochloa ischaemum and Dichanthium sericeum) are not physiologically distinct from the native C4 species they displace; therefore, the native and invading species may respond similarly to treatment techniques thus decreasing targeted management options. I established a full-factorial, completely randomized experiment to examine the interactive effects of seasonal prescribed fire and grazing on invasive grass abundance and woody brush density. Thirty-six 10m x 10m plots were assigned six treatments including: i.) summer burned-fenced ii.) summer burned-unfenced iii.) winter burned-fenced iv.) winter burned-unfenced v.) unburnedfenced vi.) unburned-unfenced. Prescribed fires were conducted in August 2013 and February 2014. Each season of burn treatment was followed by a grazing treatment. Shrub height and cover significantly decreased across all shrub species in response to fire. Fire seasonality had no effect on invasive grass abundance but grazing reduced foliar cover (p=0.02) of the dominant invader (D. sericeum). Both treatments increased total species diversity. These results indicate that both seasonal fire and grazing can be used together to decrease shrub and invasive grass cover and maintain diversity. This experiment complements another similarly designed study in South Africa, which determines the response of the encroaching shrub, Seriphium plumosum, to single season (winter) prescribed fire and grazing. Results indicate that fire can reduce shrub stature and canopy cover (p<0.01). Both treatments had no effect on herbaceous community composition (p=0.66). Comparing differential plant community responses to prescribed burn season in combination with grazing will provide important insights into the factors influencing woody vegetation dynamics and invasive grass growth and survival. This study provides a baseline of information to assist with the development of management techniques for multiple rangeland objectives

Engaging rural communities health policy

Aims & Rationale: The Alma-Ata Declaration espouses participation as a right for all citizens and important in the provision of primary health care. Australian health policy discourse encourages citizen engagement, but the extent to which this actually occurs remains unclear. Citizen engagement potentially offers considerable benefits for rural communities – a population with known health disadvantages. Drawing on results of a research project exploring the health policy implications for rural maternity care, this paper aims to (a) discuss the extent of community participation found in four rural north Queensland towns; and (b)consider how policy discourse around citizen engagement may be applied to rural health policies. Methods: Case studies of four rural north Queensland towns were completed. Observational, interview and documentary data were collected and qualitatively analysed via an inductive thematic technique. Findings: The case studies provided little indication of formal mechanisms through which community members could provide input to local health service delivery. Two communities demonstrated rapid mobilisation to rally and apply political pressure when their health services were threatened, but a distinction must be made between community action and true engagement processes. While mindful of the benefits, interviewees at all sites were particularly concerned about the barriers to successful community engagement, including: (i) overcoming community scepticism; (ii) concerns about representativeness; and (iii) community capacity. Benefits to the community: For rural communities, citizen engagement may have particular advantages in enhancing the appropriateness and responsiveness of local health services. Recommendations are made for improving rural communities' input to health policies which affect them

Hexatic and mesoscopic phases in the 2D quantum Coulomb system

We study the Wigner crystal melting in a two dimensional quantum system of particles interacting via the 1/r Coulomb potential. We use quantum Monte Carlo methods to calculate its phase diagram, locate the Wigner crystal region, and analyze its instabilities towards the liquid phase. We discuss the role of quantum effects in the critical behavior of the system, and compare our numerical results with the classical theory of melting, and the microemulsion theory of frustrated Coulomb systems. We find a Pomeranchuk effect much larger then in solid helium. In addition, we find that the exponent for the algebraic decay of the hexatic phase differs significantly from the Kosterilitz-Thouless theory of melting. We search for the existence of mesoscopic phases and find evidence of metastable bubbles but no mesoscopic phase that is stable in equilibrium

Health policy: outcomes for rural residents’ access to maternity care

Regular health care during pregnancy, birthing and the postnatal period is recommended for improving maternal and neonatal outcomes and accessing such care has become a common expectation for Australian families. Studies have highlighted the relative safety of birthing in rural hospitals even though these units are typically associated with low volumes of deliveries. Yet, in Queensland, the location and number of public maternity units shows a clear trend towards centralisation of services. During 1995- 2005, 43% of Queensland public maternity units closed, with the remaining units predominantly located in coastal and more populated locations. The closure of rural maternity units is not restricted to Queensland: the National Rural Health Alliance estimated 130 rural maternity units had closed across Australia throughout the decade 1996-20065. Growing numbers of closed rural maternity units raises considerable questions regarding the care accessed by rural residents. This paper presents findings from research conducted in north Queensland which examined the impact of health policy on an issue that is of central importance to rural communities—access to birthing services. A multi-dimensional understanding of access to maternity services was adopted in this study, a view which goes beyond measuring access only in terms of geographic distance. Gulliford et al have provided a constructive discussion of the multifaceted nature of access, particularly the differentiation between ‘having access’ and ‘gaining access’ to health care. Having access implies that a person has the opportunity to use a health service if they need or want it. This type of access is often measured in terms of doctors or hospital beds per capita and is dependent on the provision, and geographical allocation of resources, as well as the actual configuration of the network of health services. The authors draw attention to Mooney’s proposition that equal costs in using a service (eg costs of care, costs of travel, lost work) indicates equal access to services. On the other hand, gaining access to health care can be complicated by a variety of barriers including those of a personal nature (eg patients recognising their need to access health care); financial (that is, costs to be borne by the potential patient) or organisational (eg waiting lists)