Gillian K. SteelFisher

Novel pandemic A (H1N1) influenza vaccination among pregnant women: motivators and barriers

We sought to examine motivators and barriers related to monovalent 2009 influenza A (H1N1) vaccination among pregnant women. We conducted a national poll of pregnant women using a random online sample (237) and opt-in supplement (277). In all, 42% of pregnant women reported getting the vaccine. Vaccination was positively associated with attitudinal factors including believing the vaccine is very safe or benefits the baby, and with provider recommendations. Women in racial/ethnic minority groups, women with less education, and women <35 years were less likely to get the vaccine and had differing views and experiences. Despite H1N1 vaccination rates that are higher than past seasonal influenza rates, barriers like safety concerns may persist in a pandemic. Messaging from providers that encourages women to believe the vaccine is very safe and benefits their baby may be compelling. Messaging and outreach during future pandemics may require customization to increase vaccination among high-risk groups.

Physician Groups’ Use of Data from Patient Experience Surveys

BackgroundIn Massachusetts, physician groups’ performance on validated surveys of patient experience has been publicly reported since 2006. Groups also receive detailed reports of their own performance, but little is known about how physician groups have responded to these reports.ObjectiveTo examine whether and how physician groups are using patient experience data to improve patient care.Design and ParticipantsDuring 2008, we conducted semi-structured interviews with the leaders of 72 participating physician groups (out of 117 groups receiving patient experience reports). Based on leaders’ responses, we identified three levels of engagement with patient experience reporting: no efforts to improve (level 1), efforts to improve only the performance of low-scoring physicians or practice sites (level 2), and efforts to improve group-wide performance (level 3).Main MeasuresGroups’ level of engagement and specific efforts to improve patient care.Key ResultsForty-four group leaders (61%) reported group-wide improvement efforts (level 3), 16 (22%) reported efforts to improve only the performance of low-scoring physicians or practice sites (level 2), and 12 (17%) reported no performance improvement efforts (level 1). Level 3 groups were more likely than others to have an integrated medical group organizational model (84% vs. 31% at level 2 and 33% at level 1; P < 0.005) and to employ the majority of their physicians (69% vs. 25% and 20%; P < 0.05). Among level 3 groups, the most common targets for improvement were access, communication with patients, and customer service. The most commonly reported improvement initiatives were changing office workflow, providing additional training for nonclinical staff, and adopting or enhancing an electronic health record.ConclusionsDespite statewide public reporting, physician groups’ use of patient experience data varied widely. Integrated organizational models were associated with greater engagement, and efforts to enhance clinicians’ interpersonal skills were uncommon, with groups predominantly focusing on office workflow and support staff.

Public response to the 2009 influenza A H1N1 pandemic: a polling study in five countries.

BACKGROUND Many important strategies to reduce the spread of pandemic influenza need public participation. To assess public receptivity to such strategies, we compared adoption of preventive behaviours in response to the 2009 H1N1 influenza pandemic among the public in five countries and examined whether certain non-pharmaceutical behaviours (such as handwashing) were deterrents to vaccination. We also assessed public support for related public health recommendations. METHODS We used data from simultaneous telephone polls (mobile telephone and landline) in Argentina, Japan, Mexico, the UK, and the USA. In each country, interviews were done in a nationally representative sample of adults, who were selected by the use of random digit dial techniques. The questionnaire asked people whether or not they had adopted each of various preventive behaviours (non-pharmaceutical--such as personal protective and social distancing behaviour--or vaccinations) to protect themselves or their family from H1N1 at any point during the pandemic. Two-tailed t tests were used for statistical analysis. FINDINGS 900 people were surveyed in each country except the USA where 911 people were contacted. There were wide differences in the adoption of preventive behaviours between countries, although certain personal protective behaviours (eg, handwashing) were more commonly adopted than social distancing behaviours (eg, avoiding places where many people gather) across countries (53-89%vs 11-69%). These non-pharmaceutical behaviours did not reduce the likelihood of getting vaccinated in any country. There was also support across all countries for government recommendations related to school closure, avoiding places where many people gather, and wearing masks in public. INTERPRETATION There is a need for country-specific approaches in pandemic policy planning that use both non-pharmaceutical approaches and vaccination. FUNDING US Centers for Disease Control and Prevention and the National Public Health Information Coalition.

Sustaining Clinical Programs During Difficult Economic Times: A Case Series from the Hospital Elder Life Program

To explore strategies used by clinical programs to justify operations to decision‐makers using the example of the Hospital Elder Life Program (HELP), an evidence‐based, cost‐effective program to improve care for hospitalized older adults.

Ebola in the United States — Public Reactions and Implications

Despite the minimal presence of Ebola in the United States, the U.S. public expressed great concern about their risk. Such disproportionate concern, based partly on misperceptions and mistrust, may distract attention from more critical health priorities.

Motivators and barriers to using patient experience reports for performance improvement

Increasingly, patient experience surveys are available to provide performance feedback to physician groups. However, limited published literature addresses factors influencing use of these reports for performance improvement. To address this gap, we conducted semistructured interviews with leaders of Massachusetts physician groups. We asked about factors influencing groups’ use of performance data and report characteristics. Motivating characteristics included having group leaders who emphasized a positive patient experience and prioritized patient retention; public reporting was not an important motivator for most groups. Full physician panels were perceived as a barrier to use of reports. Performance reports from a statewide public reporting collaborative were not sufficient for the majority of groups, with many seeking external reports. As policy makers create financial incentives to support performance improvement, assisting leaders to articulate the professional case for patient experience and enhancing the content and timing of performance reports may be important.

Threats to polio eradication in high-conflict areas in Pakistan and Nigeria: a polling study of caregivers of children younger than 5 years

BACKGROUND Elimination of poliovirus from endemic countries is a crucial step in eradication; however, vaccination programmes in these areas face challenges, especially in regions with conflict. We analysed interviews with caregivers of children living in two polio-endemic countries to assess whether these challenges are largely operational or also driven by resistance or misinformation in the community. METHODS We designed and analysed polls based on face-to-face interviews of a random sample of parents and other caregivers of children younger than 5 years in regions of Pakistan and Nigeria at high risk for polio transmission. In both countries, the sample was drawn via a stratified multistage cluster design with random route household selection. The questionnaire covered awareness, knowledge, and attitudes about polio and oral polio vaccine (OPV), trust in vaccination efforts, and caregiver priorities for government action. We assessed experiences of caregivers in accessible higher-conflict areas and compared their knowledge and attitudes with those in lower-conflict areas. Differences were tested with two-sample t tests. FINDINGS The poll consisted of 3396 caregivers from Pakistan and 2629 from Nigeria. About a third of caregivers who responded in higher-conflict areas of Pakistan (Federally Administered Tribal Areas [FATA], 30%) and Nigeria (Borno, 33%) were unable to confirm that their child was vaccinated in the previous campaign. In FATA, 12% of caregivers reported that they were unaware of polio, and in Borno 12% of caregivers reported that vaccinators visited but their child did not receive the vaccine or they did not know whether the child was vaccinated. Additionally, caregivers in higher-conflict areas are less likely to hold beliefs about OPV that could motivate acceptance and are more likely to hold concerns than are caregivers in lower-conflict areas. INTERPRETATION Beyond the difficulties in reaching homes with OPV, challenges for vaccination programmes in higher-conflict areas extend to limited awareness, negative attitudes, and gaps in trust. Vaccination efforts might need to address underlying attitudes of caregivers through direct communications and the selection and training of local vaccinators. FUNDING Harvard T H Chan School of Public Health and UNICEF.

Learning from the Closure of Clinical Programs: A Case Series from the Hospital Elder Life Program

Clinical programs in geriatrics face a challenging fiscal environment. Although recent research offers lessons from successful programs to help others like them sustain operations, it is not clear whether these lessons apply to programs that are beginning to fail. This study takes an approach that is frequently recommended, but rarely applied: examining failed programs to develop guidance for those at risk. It uses the example of an evidence‐based, cost‐effective geriatrics program that has been successfully implemented at more than 200 sites: the Hospital Elder Life Program (HELP). Data come from 14 in‐depth interviews conducted between January and May 2011 with staff and hospital administrators affiliated with the six fully operational sites that closed between 2006 and 2011. Using the constant comparative method, researchers identified major themes suggesting that former HELP sites closed because of two interrelated problems centered on a major financial crisis or restructuring at the hospital or health system level. First, the crisis created challenges, such as the removal of program champions and a new focus on revenue‐generating programs. Second, there were on‐going vulnerabilities that the crisis revealed but that had not previously posed a threat to program viability. These included problems such as insufficient support from physicians and nursing leaders and limited documentation of program outcomes. Results suggest that, to protect against closure, clinical programs need to prepare for major crises at the hospital or health system level by ensuring support from multiple senior champions, with a special emphasis on nursing and physician leaders.

Adoption of preventive behaviors in response to the 2009 H1N1 influenza pandemic: a multiethnic perspective

As public health leaders prepare for possible future influenza pandemics, the rapid spread of 2009 H1N1 influenza highlights the need to focus on measures the public can adopt to help slow disease transmission. Such measures may relate to hygiene (e.g., hand washing), social distancing (e.g., avoiding places where many people gather), and pharmaceutical interventions (e.g., vaccination). Given the disproportionate impact of public health emergencies on minority communities in the United States, it is important to understand whether there are differences in acceptance across racial/ethnic groups that could lead to targeted and more effective policies and communications.

Can Quality Reports Help Address Health Care Disparities?: Use and Awareness of Comparative Quality Information by African Americans

Comparative quality information (CQInfo) might help ameliorate racial disparities in health care. However, barriers such as low literacy and non-representative materials may make African Americans less likely than Whites to use CQInfo, thus diminishing its effect. Therefore, this analysis sought to evaluate racial differences in awareness and use of CQInfo using a national, random digit dial telephone survey. Results show that African Americans were less likely than Whites to have seen CQInfo concerning hospitals and doctors (not health plans), but were not less likely to have used it. Conditional on awareness, African Americans were more likely than Whites to have used this information. In logistic regressions controlling for other demographic characteristics, racial differences in awareness remained marginally significant statistically and differences in conditional use disappeared. Findings suggest a demand for CQInfo among African Americans, and support the idea that such information could help ameliorate racial disparities, if efforts also address educational and other related barriers.