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Importance Health care workers (HCW) faced chronic stress during the COVID-19 pandemic and were at high risk of illness, death and burnout. Objective To understand the experiences of and assess the acceptability and usability of the “Stress First Aid” (SFA) intervention for HCWs. Design We used a mixed methods approach to conduct: (1) a quantitative post-intervention survey of experiences with the SFA intervention within a cluster randomized controlled trial (cRCT); and (2) a qualitative descriptive analysis. The intervention was rolled out over three waves from March 2021 – October 2022 simultaneously with the sites’ COVID-19 response. Setting Our team engaged and recruited eight pairs of hospitals and six pairs of Federally Qualified Health Centers (FQHCs), balanced across region, including nine states, and matched on size, type, and COVID-19 burden. Participants A total of 862 HCWs received the SFA intervention and completed both the pre- and post-intervention surveys (FQHC n  = 245 and hospital n  = 617). For the qualitative analysis, among HCWs who agreed to be contacted for a post-intervention interview, we purposively sampled a subset of 35 HCWs balanced by site, gender, age, race/ethnicity and HCW type. Intervention SFA is an evidence-informed intervention adapted to mitigate the psychosocial impact of COVID-19 on HCWs through individual peer support actions. Main Outcome(s) and Measure(s) Quantitative measures are binary indicators of agreement with 6 questions about experiences with the SFA intervention. For the qualitative analysis, we utilized a semi-structured interview protocol to provide additional context on experience with SFA and how SFA affects HCW well-being. Results Between 48.2 and 59.4% of HCWs agreed or strongly agreed that they: found SFA helpful (48.2%), felt comfortable supporting colleagues (59.4%), would recommend SFA (51.2%), and would continue to use SFA principles (57.2%). Non-White HCWs (particularly Black HCWs), those in assistant/technician positions and those who reported attending a greater number of booster sessions were more likely to agree with positive statements about SFA experiences. Conclusions and Relevance Given the continued resurgence of public health emergencies, its lasting effects on HCWs, and related emerging challenges, we expect there to be a continued need for support of patient-facing HCWs. Clinical trial registration Clinical Trials.gov Number: NCT04723576 Registered on 01/22/2021 Clinicaltrials.govNCT04723576.

Substantial variation exists in surgeon decision making. In response, multiple specialty societies have established criteria for the appropriate use of spine surgery. Yet few strategies exist to facilitate routine use of appropriateness criteria by surgeons. Behavioral science nudges are increasingly used to enhance decision making by clinicians. We sought to design \"surgical appropriateness nudges\" to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis. The work reflected Stage I of the NIH Stage Model for Behavioral Intervention Development and involved an iterative, multi-method approach, emphasizing qualitative methods. Study sites included two large referral centers for spine surgery. We recruited spine surgeons from both sites for two rounds of focus groups. To produce preliminary nudge prototypes, we examined sources of variation in surgeon decision making (Focus Group 1) and synthesized existing knowledge of appropriateness criteria, behavioral science nudge frameworks, electronic tools, and the surgical workflow. We refined nudge prototypes via feedback from content experts, site leaders, and spine surgeons (Focus Group 2). Concurrently, we collected data on surgical practices and outcomes at study sites. We pilot tested the refined nudge prototypes among spine surgeons, and surveyed them about nudge applicability, acceptability, and feasibility (scale 1-5, 5 = strongly agree). Fifteen surgeons participated in focus groups, giving substantive input and feedback on nudge design. Refined nudge prototypes included: individualized surgeon score cards (frameworks: descriptive social norms/peer comparison/feedback), online calculators embedded in the EHR (decision aid/mapping), a multispecialty case conference (injunctive norms/social influence), and a preoperative check (reminders/ salience of information/ accountable justification). Two nudges (score cards, preop checks) incorporated data on surgeon practices and outcomes. Six surgeons pilot tested the refined nudges, and five completed the survey (83%). The overall mean score was 4.0 (standard deviation [SD] 0.5), with scores of 3.9 (SD 0.5) for applicability, 4.1 (SD 0.5) for acceptability, and 4.0 (SD 0.5), for feasibility. Conferences had the highest scores 4.3 (SD 0.6) and calculators the lowest 3.9 (SD 0.4). Behavioral science nudges might be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow of spine surgeons. Future stages in intervention development will test whether these surgical appropriateness nudges can be implemented in practice and influence surgical decision making.

To conduct a cross-national comparative study of the prevalence and correlates of female genital cutting (FGC) practices and beliefs in western Africa. Data from women who responded to the Multiple Indicator Cluster Surveys between 2005 and 2007 were used to estimate the frequencies of ever having been circumcised, having had a daughter circumcised, and believing that FGC practices should continue. Weighted logistic regression using data for each country was performed to determine the independent correlates of each outcome. The prevalence of FGC was high overall but varied substantially across countries in western Africa. In Sierra Leone, Gambia, Burkina Faso and Mauritania, the prevalence of FGC was 94%, 79%, 74% and 72%, respectively, whereas in Ghana, Niger and Togo prevalence was less than 6%. Older age and being Muslim were generally associated with increased odds of FGC, and higher education was associated with lower odds of FGC. The association between FGC and wealth varied considerably. Burkina Faso was the only country in our study that experienced a dramatic reduction in FGC prevalence from women (74%) to their daughters (25%); only 14.2% of the women surveyed in that country said that they believe the practice should continue. The prevalence of FGC in western Africa remains high overall but varies substantially across countries. Given the broad range of experiences, successful strategies from countries where FGC is declining may provide useful examples for high-prevalence countries seeking to reduce their own FGC practices.

BackgroundPrevious studies have documented income differences between male and female physicians. However, the implications of these differences are unclear, since previous studies have lacked detailed data on the quantity and composition of work hours. We sought to identify the sources of these income differences using data from a novel survey of physician work and income.ObjectiveTo compare differences in income between male and female physicians.DesignWe estimated unadjusted income differences between male and female physicians. We then adjusted these differences for total hours worked, composition of work hours, percent of patient care time spent providing procedures, specialty, compensation type, age, years in practice, race, ethnicity, and state and practice random effects.ParticipantsWe surveyed 656 physicians in 30 practices in six states and received 439 responses (67% response rate): 263 from males and 176 from females.Main measureSelf-reported annual income.Key resultsMale physicians had significantly higher annual incomes than female physicians (mean$297,641 vs. $ 206,751; difference$90,890, 95% CI $ 27,769 to$154,011) and worked significantly more total hours (mean 2470 vs. 2074; difference 396, 95% CI 250 to 542) and more patient care hours (mean 2203 vs. 1845; difference 358, 95% CI 212 to 505) per year. Male physicians were less likely than female physicians to specialize in primary care (49.1 vs. 70.5%), but more likely to perform procedures with (33.1 vs. 15.5%) or without general anesthesia (84.3 vs. 73.1%). After adjustment, male physicians’ incomes were $ 27,404 (95% CI$3120 to $ 51,688) greater than female physicians’ incomes.ConclusionsAdjustment for multiple possible confounders, including the number and composition of work hours, can explain approximately 70% of unadjusted income differences between male and female physicians; 30% remains unexplained. Additional study and dedicated efforts might be necessary to identify and address the causes of these unexplained differences.

Numerous forecasts have predicted shortages of primary care providers, particularly in light of an expected increase in patient demand resulting from the Affordable Care Act. Yet these forecasts could be inaccurate because they generally do not allow for changes in the way primary care is delivered. The authors analyzed the impact of two emerging models of care -- the patient-centered medical home and the nurse-managed health center -- both of which use a provider mix that is richer in nurse practitioners and physician assistants than today's predominant models of care delivery. They found that projected physician shortages were substantially reduced in plausible scenarios that envisioned greater reliance on these new models, even without increases in the supply of physicians. Some less plausible scenarios even eliminated the shortage. All of these scenarios, however, may require additional changes, such as liberalized scope-of-practice laws; a larger supply of medical assistants, licensed practical nurses, and aides; and payment changes that reward providers for population health management. Adapted from the source document.

The American Medical Association asked RAND Health to characterize the factors that affect physician professional satisfaction. RAND researchers sought to identify high-priority determinants of professional satisfaction by gathering data from 30 physician practices in six states, using a combination of surveys and semistructured interviews. This report presents the results of the subsequent analysis.

Foreign-educated and foreign-born health workers constitute a sizable and important portion of the US health care workforce. We review the distribution of these workers and their countries of origin, and we summarize the literature concerning their contributions to US health care. We also report on these workers' experiences in the United States and the impact their migration has on their home countries. Finally, we present policy strategies to increase the benefits of health care worker migration to the United States while mitigating its negative effects on the workers' home countries. These strategies include attracting more people with legal permanent residency status into the health workforce, reimbursing home countries for the cost of educating health workers who subsequently migrate to the United States, improving policies to facilitate the entry of direct care workers into the country, advancing efforts to promote and monitor ethical migration and recruitment practices, and encouraging the implementation of programs by US employers to improve the experience of immigrating health workers. [PUBLICATION ABSTRACT]

To examine the association between breastfeeding duration and sources of education about breastfeeding and breast pumps. We analyzed data from the Infant Feeding Practices Survey II ( n  = 2,586), a national longitudinal consumer-based study. We used χ 2 and ANOVA to contrast categorical and continuous variables, respectively, and logistic regression to model the association between breastfeeding duration and sources of education about breastfeeding and breast pump use. In unadjusted results, multiple sources of breastfeeding and breast pump education were significantly associated with breastfeeding duration. However, in multivariable logistic regression models, there was a negative association between longer breastfeeding duration and receiving breast pump education from a physician/physician assistant (OR 0.58, 95% CI 0.36–0.93); and a positive association between longer breastfeeding duration and receiving breastfeeding education from classes/support group (OR: 1.85, 95% CI: 1.24–2.76) and receiving breast pump education from friends/relatives (OR: 1.70, 95% CI: 1.13–2.55). Although healthcare providers such as physicians and nurses have regular contact with women, the only statistically significant association between breastfeeding and breast pump education from healthcare providers and longer breastfeeding duration was a negative one. This likely reflects time and resource limitations of clinical practice, but may also indicate a need for more consistent training for healthcare providers who provide breastfeeding and breast pump education. Social supports, such as education from classes/support groups and friends/relatives demonstrated positive associations with longer breastfeeding duration. This emphasizes the importance of fostering a positive sphere of influence around breastfeeding women. Future work should also investigate alternative levers of action, such as policies affecting insurance coverage of breast pumps.

Background Despite greater risk of cardiovascular disease (CVD) mortality in patients with a history of incarceration, little is known about how prisons manage CVD risk factors (CVD-RF) to mitigate this risk. Methods We conducted in-depth interviews with individuals with CVD-RF who had been recently released from prison ( n  = 26). These individuals were recruited through community flyers and a primary care clinic in Connecticut. Using a grounded theory approach and the constant comparative method, we inductively generated themes about CVD-RF care in prisons. Data collection and analysis occurred iteratively to refine and unify emerging themes. Results Four themes emerged about care in prison: (1) Participants perceive that their CVD-RFs are managed through acute, rather than chronic, care processes; (2) Prison providers’ multiple correctional and medical roles can undermine patient-centered care; (3) Informal support systems can enhance CVD-RF self-management education and skills; and (4) The trade-off between prisoner security and patient autonomy influences opportunities for self-management. Conclusions Patients develop self-management skills through complex processes that may be compromised by the influence of correctional policies on medical care. Our findings support interventions to engage peers, medical providers, care delivery systems, and correctional staff in cultivating effective self-management strategies tailored to prison settings.