Ashley Lacombe-Duncan

Integrated complex care coordination for children with medical complexity: A mixed-methods evaluation of tertiary care-community collaboration

BackgroundPrimary care medical homes may improve health outcomes for children with special healthcare needs (CSHCN), by improving care coordination. However, community-based primary care practices may be challenged to deliver comprehensive care coordination to complex subsets of CSHCN such as children with medical complexity (CMC). Linking a tertiary care center with the community may achieve cost effective and high quality care for CMC. The objective of this study was to evaluate the outcomes of community-based complex care clinics integrated with a tertiary care center.MethodsA before- and after-intervention study design with mixed (quantitative/qualitative) methods was utilized. Clinics at two community hospitals distant from tertiary care were staffed by local community pediatricians with the tertiary care center nurse practitioner and linked with primary care providers. Eighty-one children with underlying chronic conditions, fragility, requirement for high intensity care and/or technology assistance, and involvement of multiple providers participated. Main outcome measures included health care utilization and expenditures, parent reports of parent- and child-quality of life [QOL (SF-36®, CPCHILD©, PedsQL™)], and family-centered care (MPOC-20®). Comparisons were made in equal (up to 1 year) pre- and post-periods supplemented by qualitative perspectives of families and pediatricians.ResultsTotal health care system costs decreased from median (IQR)

A qualitative analysis of information sharing for children with medical complexity within and across health care organizations

244 (981) per patient per month (PPPM) pre-enrolment to

Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston, Jamaica: a qualitative study

131 (355) PPPM post-enrolment (p=.007), driven primarily by fewer inpatient days in the tertiary care center (p=.006). Parents reported decreased out of pocket expenses (p<.0001). Parental QOL did not significantly change over the course of the study. Child QOL improved between baseline and 6 months in two PedsQL™ domains [Social (p=.01); Emotional (p=.003)], and between baseline and 1 year in two CPCHILD© domains [Health Standardization Section (p=.04); Comfort and Emotions (p=.03)], while total CPCHILD© score decreased between baseline and 1 year (p=.003). Parents and providers reported the ability to receive care close to home as a key benefit.ConclusionsComplex care can be provided in community-based settings with less direct tertiary care involvement through an integrated clinic. Improvements in health care utilization and family-centeredness of care can be achieved despite minimal changes in parental perceptions of child health.

Family Experiences With Feeding Tubes in Neurologic Impairment: A Systematic Review

BackgroundChildren with medical complexity (CMC) are characterized by substantial family-identified service needs, chronic and severe conditions, functional limitations, and high health care use. Information exchange is critically important in high quality care of complex patients at high risk for poor care coordination. Written care plans for CMC are an excellent test case for how well information sharing is currently occurring. The purpose of this study was to identify the barriers to and facilitators of information sharing for CMC across providers, care settings, and families.MethodsA qualitative study design with data analysis informed by a grounded theory approach was utilized. Two independent coders conducted secondary analysis of interviews with parents of CMC and health care professionals involved in the care of CMC, collected from two studies of healthcare service delivery for this population. Additional interviews were conducted with privacy officers of associated organizations to supplement these data. Emerging themes related to barriers and facilitators to information sharing were identified by the two coders and the research team, and a theory of facilitators and barriers to information exchange evolved.ResultsBarriers to information sharing were related to one of three major themes; 1) the lack of an integrated, accessible, secure platform on which summative health care information is stored, 2) fragmentation of the current health system, and 3) the lack of consistent policies, standards, and organizational priorities across organizations for information sharing. Facilitators of information sharing were related to improving accessibility to a common document, expanding the use of technology, and improving upon a structured communication plan.ConclusionsFindings informed a model of how various barriers to information sharing interact to prevent optimal information sharing both within and across organizations and how the use of technology to improve communication and access to information can act as a solution.

Patterns of cigarillo use among Canadian young adults in two urban settings

Introduction: Young men who have sex with men (MSM) in Jamaica have the highest HIV prevalence in the Caribbean. There is little information about HIV among transgender women in Jamaica, who are also overrepresented in the Caribbean epidemic. HIV‐related stigma is a barrier to HIV testing among Jamaicas general population, yet little is known of MSM and transgender womens HIV testing experiences in Jamaica. We explored perceived barriers and facilitators to HIV testing among young MSM and transgender women in Kingston, Jamaica.

Prevalence, motivations, and social, mental health and health consequences of cyberbullying among school-aged children and youth: protocol of a longitudinal and multi-perspective mixed method study

BACKGROUND AND OBJECTIVE: Gastrostomy tubes (G-tubes) are frequently used to provide enteral nutrition for children who have neurologic impairment. Understanding the impact of G-tubes from the family’s perspective will inform decision-making and improve support from health care providers. This study explored the experiences of families after G-tube placement in children with neurologic impairment. METHODS: We conducted a systematic review of English-language qualitative primary research studies describing family experiences after G-tube placement. Six electronic databases were searched from inception to June 2014. Two authors independently screened and identified relevant studies, evaluated quality of reporting by using the Consolidated Criteria for Reporting Qualitative Research tool, and extracted data. Overarching concepts were developed by using thematic analysis. RESULTS: From 2674 screened abstracts, 84 texts were reviewed, and 13 studies met the inclusion criteria. G-tubes affect the lives of children, parents, and the family unit in many ways, both positive and negative. Improvements and challenges were described for children’s health and happiness, for parental caregiving and stress, and for logistics and bonding within the family. G-tube feeding also changed relationships within the family, between the family and the medical system, and between the family and the outside world. Furthermore, experiences varied, with different families framing similar concepts as positive and negative. CONCLUSIONS: G-tube placement has diverse effects on daily life for children with neurologic impairment and their families. Clinicians may use the themes identified in this study to guide conversations with families about their values, experiences, and expectations before and after G-tube placement.

Factors associated with sex work involvement among transgender women in Jamaica: A cross-sectional study

OBJECTIVES: Current estimates indicate that cigarillo use has become commonplace among young adults in Canada despite the established risks to health. However, little else is known about patterns of cigarillo use in this subpopulation. The intent of this research was to examine the patterns, attitudes, and beliefs regarding cigarillo use and co-use of cigarillos and cigarettes among Canadian young adults.METHODS: Canadians aged 19–29 years from the Greater Toronto Area, Ontario and Edmonton, Alberta were recruited from September 2009 to February 2010 and in June 2010, respectively (n=133). Eligible participants completed questionnaires assessing cigarillo, cigarette, and cannabis use; social influence of usage; and beliefs about cigarillo use.RESULTS: Cigarillo use was common in social settings, with friends, and during leisure time. The majority of participants were co-users of cigarillos and cigarettes (82%), and currently used cannabis (72%). Respondents reported “replacing cigarette smoking” and “flavour” as main reasons for smoking cigarillos; and half (52%) believed they were not at all addicted to cigarillos. Disconcertingly, participants perceived the risk of cancer attributed to smoking cigarillos as significantly less than the risk of cancer attributed to smoking cigarettes (p<0.0001).CONCLUSION: These findings highlight the social nature of cigarillo use, and suggest a lack of awareness of the health risks associated with cigarillo and polytobacco use in this small convenience sample of Canadian young adults. Population-level analyses are needed to further investigate cigarillo, polytobacco and concurrent cannabis use patterns and beliefs among Canadian young adults.RésuméOBJECTIFS: Selon les estimations actuelles, l’usage de cigarillos s’est banalisé chez les jeunes adultes au Canada malgré ses risques démontrés pour la santé. Cependant, on n’en sait guère plus sur les habitudes d’usage des cigarillos dans cette sous-population. Nous avons cherché à examiner les habitudes, les attitudes et les croyances liées à l’usage de cigarillos et au co-usage de cigarillos et de cigarettes chez les jeunes adultes canadiens.METHODE: Des Canadiens âgés de 19 à 29 ans vivant dans la région du Grand Toronto (Ontario) et à Edmonton (Alberta) ont été recrutés de septembre 2009 à février 2010 et en juin 2010, respectivement (n= 33). Les participants admissibles ont rempli des questionnaires d’évaluation sur leur usage des cigarillos, des cigarettes et du cannabis; l’influence sociale de cet usage; et leurs croyances au sujet de l’usage de cigarillos.RÉSULTATS: L’usage de cigarillos était courant dans des situations sociales, entre amis et dans les temps libres. Les participants étaient en majorité des co-utilisateurs de cigarillos et de cigarettes (82 %) et des consommateurs actuels de cannabis (72 %). Les principales raisons citées par les répondants pour expliquer leur usage de cigarillos étaient le «remplacement de l’usage de la cigarette» et «l’arôme»; et la moitié (52 %) croyait n’avoir aucune dépendance aux cigarillos. Curieusement, les participants percevaient le risque de cancer imputé à l’usage de cigarillos comme étant beaucoup moins important que le risque imputé à l’usage de cigarettes (p<0,0001).CONCLUSION: Ces constatations soulignent la nature sociale de l’usage des cigarillos et donnent à penser que dans ce petit échantillon de commodité de jeunes adultes canadiens, on méconnaît les risques sanitaires associés à l’usage de cigarillos et au poly-usage de tabac. Des analyses populationnelles sont nécessaires pour étudier plus avant les habitudes et les croyances liées à l’usage de cigarillos et au poly-usage de tabac, ainsi qu’à la consommation parallèle de cannabis, chez les jeunes adultes canadiens.

Understanding the Association Between Chronic Obstructive Pulmonary Disease and Current Anxiety: A Population-Based Study

Background While the online environment may promote important developmental and social benefits, it also enables the serious and rapidly growing issue of cyberbullying. Cyberbullying constitutes an increasing public health problem – victimized children and youth experience a range of health and mental health concerns, including emotional and psychosomatic problems, maladaptive behaviors, and increased suicidality. Perpetrators demonstrate a lack of empathy, and may also struggle with health and mental health issues. Objective This paper describes the protocols applied in a longitudinal and multi-perspective mixed-methods study with five objectives: (1) to explore children/youth’s experiences, and children/youth’s, parents’, and teachers’ conceptions, definitions, and understanding of cyberbullying; (2) to explore how children/youth view the underlying motivations for cyberbullying; (3) to document the shifting prevalence rates of cyberbullying victimization, witnessing, and perpetration; (4) to identify risk and protective factors for cyberbullying involvement; and (5) to explore social, mental health, and health consequences of cyberbullying. Methods Quantitative survey data were collected over three years (2012-2014) from a stratified random baseline sample of fourth (n=160), seventh (n=243), and tenth (n=267) grade children/youth, their parents (n=246), and their teachers (n=103). Quantitative data were collected from students and teachers during in-person school visits, and from parents via mail-in surveys. Student, parent, and teacher surveys included questions regarding: student experiences with bullying/cyberbullying; student health, mental health, and social and behavioral issues; socio-demographics; and information and communication technology use. In-depth semi-structured qualitative interviews were conducted twice with a sub-sample of students (n=57), purposively selected based on socio-demographics and cyberbullying experience, twice with their parents (n=50), and once with their teachers (n=30). Results Data collection for this study is complete. Planned analyses include transition probabilities and repeated measures analyses to determine involvement in cyberbullying. Repeated measures analyses, including between-subject factors (eg, socio-demographics), will be utilized to determine factors that protect or increase risk of involvement in cyberbullying. Qualitative analysis utilizing grounded theory is planned, to permit rich understanding of participant experiences and perspectives. Results will be reported in 2016 and 2017. Conclusions This study will offer insight into the contemporary phenomenon of cyberbullying while also informing interventions to curb cyberbullying and address its pervasive social, mental health, and health consequences. Knowledge mobilization strategies and implications for research and practice are discussed.

Community engagement among men who have sex with men living with HIV/AIDS in Taiwan

Introduction: Transgender women are disproportionately impacted by HIV. Transgender women involved in sex work may experience exacerbated violence, social exclusion, and HIV vulnerabilities, in comparison with non‐sex work‐involved transgender women. Scant research has investigated sex work among transgender women in the Caribbean, including Jamaica, where transgender women report pervasive violence. The study objective was to examine factors associated with sex work involvement among transgender women in Jamaica.

Taking culture seriously in biomedical HIV prevention trials: a meta-synthesis of qualitative studies.

Abstract This studys objectives were to investigate the independent relationship between COPD and past-year Generalized Anxiety Disorder (GAD) in a population-based sample of adult Canadians and to identify significant correlates of GAD among COPD patients. A series of logistic regression analyses were conducted with a sample of 11,163 respondents aged 50+ from the 2012 Canadian Community Health Survey–Mental Health to determine the degree to which the direct association between COPD and GAD was attenuated by socio-demographic factors, social support, health behaviors, sleep problems, pain, functional limitations, and early childhood adversities. Additional analyses were completed using the sub-sample of those diagnosed with COPD (n = 746) to determine predictors of GAD. One in 17 (5.8%) of older individuals with COPD had past-year GAD, in comparison to 1.7% of those without (p < .001). The age-sex-race adjusted odds of GAD were four times higher for those with COPD compared to those without COPD (OR = 3.90, 95%CI: 2.64, 5.77). After full adjustment for 18 characteristics, these odds declined to 1.72 (95%CI: 1.10, 2.71). Factors associated with GAD among those with COPD include not having a confidant (OR = 7.85, 95%CI: 3.47, 17.75), exposure to parental domestic violence (OR = 5.63, 95% CI: 2.07, 15.34) and lifetime depressive disorders (OR = 3.59, 95% CI:1.61,7.98). Those with COPD have substantially higher odds of GAD even after most known risk factors for GAD are accounted for. These findings have implications for targeted outreach and screening, particularly for patients with pain and functional limitations. The importance of a multidisciplinary healthcare team is underscored by the multiple issues that may impact GAD among COPD patients.