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Yet not everyone appreciates their efforts and contributions. Since the beginning of this pandemic, headlines have also captured stories of health-care personnel facing attacks as they travel to and from health-care facilities. Governmental failures in some countries to adequately provide and manage resources in this pandemic mean that health-care personnel are risking their lives daily by caring for COVID-19 patients without adequate personal protective equipment and other safety measures in their workplaces.7 As a result, thousands of health-care workers worldwide have contracted severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and have thus been perceived as public health hazards themselves.8 This situation has generated violence against them in some places, essentially for performing their professional duties. [...]this initiative must incorporate lessons learned from previous efforts to document violence against health-care personnel, such as attacks on those leading polio vaccination campaigns or who cared for patients with Ebola virus disease.10 Data on attacks specific to COVID-19 should be systematically gathered and included in the WHO Surveillance System of Attacks on Healthcare. [...]health professional associations, societies, and organisations from all specialties and disciplines should unite in speaking out forcefully against all acts of discrimination, intimidation, and violence against health-care workers.15 They must immediately condemn violence when it occurs and participate in initiatives aimed at responding to and eliminating violence.

Primary care-based models for Medication-Assisted Treatment (MAT) have been shown to reduce mortality for Opioid Use Disorder (OUD) and have equivalent efficacy to MAT in specialty substance treatment facilities. The objective of this study is to systematically analyze current evidence-based, primary care OUD MAT interventions and identify program structures and processes associated with improved patient outcomes in order to guide future policy and implementation in primary care settings. PubMed, EMBASE, CINAHL, and PsychInfo. We included randomized controlled or quasi experimental trials and observational studies evaluating OUD treatment in primary care settings treating adult patient populations and assessed structural domains using an established systems engineering framework. We included 35 interventions (10 RCTs and 25 quasi-experimental interventions) that all tested MAT, buprenorphine or methadone, in primary care settings across 8 countries. Most included interventions used joint multi-disciplinary (specialty addiction services combined with primary care) and coordinated care by physician and non-physician provider delivery models to provide MAT. Despite large variability in reported patient outcomes, processes, and tasks/tools used, similar key design factors arose among successful programs including integrated clinical teams with support staff who were often advanced practice clinicians (nurses and pharmacists) as clinical care managers, incorporating patient \"agreements,\" and using home inductions to make treatment more convenient for patients and providers. The findings suggest that multidisciplinary and coordinated care delivery models are an effective strategy to implement OUD treatment and increase MAT access in primary care, but research directly comparing specific structures and processes of care models is still needed.

Overview of Peer Support Models to Improve Diabetes Self-Management and Clinical Outcomes Michele Heisler , MD, MPA Abstract In Brief This article provides a brief overview of different approaches to mobilize peer support for diabetes self-management support and evidence to date on the effectiveness of each of these models with an emphasis on research into ways to extend face-to-face programs using innovative technologies. It concludes with a discussion of directions for future research in this area. Footnotes Michele Heisler, MD, MPA, is a research scientist at the Veterans Affairs Center for Clinical Practice Management Research, VA Ann Arbor Healthcare System, and an assistant professor in the Department of Internal Medicine at the University of Michigan Medical School in Ann Arbor. American Diabetes Association

Background Research to date has focused on strategies and resources used by effective champions of healthcare change efforts, rather than personal characteristics that contribute to their success. We sought to identify and describe champion attributes influencing outcomes of healthcare change efforts. To examine attributes of champions, we used postpartum contraceptive care as a case study, because recommended services are largely unavailable, and implementation requires significant effort. Methods We conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 U.S. maternity hospitals in 2017–18. We conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research (CFIR). Phase one analysis (qualitative content analysis using a priori CFIR codes and cross-case synthesis) showed that implementation leaders (“champions”) strongly influenced outcomes across sites. To understand champion effects, phase two inductive analysis included (1) identifying and elaborating key attributes of champions; (2) rating the presence or absence of each attribute in champions; and 3) cross-case synthesis to identify patterns among attributes, context, and implementation outcomes. Results We completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. All identified champions were obstetrician-gynecologists. Six key attributes of champions emerged: influence, ownership, physical presence at the point of change, persuasiveness, grit, and participative leadership style. These attributes promoted success by enabling champions to overcome institutional siloing, build and leverage professional networks, create tension for change, cultivate a positive learning climate, optimize compatibility with existing workflow, and engage key stakeholders. Not all champion attributes were required for success, and having all attributes did not guarantee success. Conclusions Effective champions appear to leverage six key attributes to facilitate healthcare change efforts. Prospective evaluations of the interactions among champion attributes, context, and outcomes may further elucidate how champions exert their effects.

The U.S. government forcibly separated more than 5,000 children from their parents between 2017 and 2018 through its “Zero Tolerance” policy. It is unknown how many of the children have since been reunited with their parents. As of August 1, 2021, however, at least 1,841 children are still separated from their parents. This study systematically examined narratives obtained as part of a medico-legal process by trained clinical experts who interviewed and evaluated parents and children who had been forcibly separated. The data analysis demonstrated that 1) parents and children shared similar pre-migration traumas and the event of forced family separation in the U.S.; 2) they reported signs and symptoms of trauma following reunification; 3) almost all individuals met criteria for DSM diagnoses, even after reunification; 4) evaluating clinicians consistently concluded that mental health treatment was indicated for both parents and children; and 5) signs of malingering were absent in all cases.

Primary care patients with obesity seldom receive effective weight management treatment in primary care settings. This study aims to understand PCPs' perspectives on obesity treatment barriers and opportunities to overcome them. This is an explanatory sequential mixed methods study in which survey data was collected and used to inform subsequent qualitative interviews. PCPs who provide care to adult patients in an academic medical center in the Midwestern US. PCPs (n = 350) were invited by email to participate in an online survey. PCPs were subsequently invited to participate in semi-structured interviews to further explore survey domains. Survey data were analyzed using descriptive statistics. Interviews were analyzed using directed content analysis. Among 107 survey respondents, less than 10% (n = 8) used evidence-based guidelines to inform obesity treatment decisions. PCPs' identified opportunities to improve obesity treatment including (1) education on local obesity treatment resources (n = 78, 73%), evidence-based dietary counseling strategies (n = 67, 63%), and effective self-help resources (n = 75, 70%) and (2) enhanced team-based care with support from clinic staff (n = 53, 46%), peers trained in obesity medicine (n = 47, 44%), and dietitians (n = 58, 54%). PCPs also desired increased reimbursement for obesity treatment. While 40% (n = 39) of survey respondents expressed interest in obesity medicine training and certification through the American Board of Obesity Medicine, qualitative interviewees felt that pursuing training would require dedicated time (i.e., reduced clinical effort) and financial support. Opportunities to improve obesity treatment in primary care settings include educational initiatives, use of team-based care models, and policy changes to incentivize obesity treatment. Primary care clinics or health systems should be encouraged to identify PCPs with specific interests in obesity medicine and support their training and certification through ABOM by reimbursing training costs and reducing clinical effort to allow for study and board examination.

Effective health system interventions may help address the disproportionate burden of diabetes in low- and middle-income countries (LMICs). We assessed the impact of health system interventions to improve outcomes for adults with type 2 diabetes in LMICs. We searched Ovid MEDLINE, Cochrane Library, EMBASE, African Index Medicus, LILACS, and Global Index Medicus from inception of each database through February 24, 2020. We included randomized controlled trials (RCTs) of health system interventions targeting adults with type 2 diabetes in LMICs. Eligible studies reported at least 1 of the following outcomes: glycemic change, mortality, quality of life, or cost-effectiveness. We conducted a meta-analysis for the glycemic outcome of hemoglobin A1c (HbA1c). GRADE and Cochrane Effective Practice and Organisation of Care methods were used to assess risk of bias for the glycemic outcome and to prepare a summary of findings table. Of the 12,921 references identified in searches, we included 39 studies in the narrative review of which 19 were cluster RCTs and 20 were individual RCTs. The greatest number of studies were conducted in the East Asia and Pacific region (n = 20) followed by South Asia (n = 7). There were 21,080 total participants enrolled across included studies and 10,060 total participants in the meta-analysis of HbA1c when accounting for the design effect of cluster RCTs. Non-glycemic outcomes of mortality, health-related quality of life, and cost-effectiveness had sparse data availability that precluded quantitative pooling. In the meta-analysis of HbA1c from 35 of the included studies, the mean difference was -0.46% (95% CI -0.60% to -0.31%, I2 87.8%, p < 0.001) overall, -0.37% (95% CI -0.64% to -0.10%, I2 60.0%, n = 7, p = 0.020) in multicomponent clinic-based interventions, -0.87% (-1.20% to -0.53%, I2 91.0%, n = 13, p < 0.001) in pharmacist task-sharing studies, and -0.27% (-0.50% to -0.04%, I2 64.1%, n = 7, p = 0.010) in trials of diabetes education or support alone. Other types of interventions had few included studies. Eight studies were at low risk of bias for the summary assessment of glycemic control, 15 studies were at unclear risk, and 16 studies were at high risk. The certainty of evidence for glycemic control by subgroup was moderate for multicomponent clinic-based interventions but was low or very low for other intervention types. Limitations include the lack of consensus definitions for health system interventions, differences in the quality of underlying studies, and sparse data availability for non-glycemic outcomes. In this meta-analysis, we found that health system interventions for type 2 diabetes may be effective in improving glycemic control in LMICs, but few studies are available from rural areas or low- or lower-middle-income countries. Multicomponent clinic-based interventions had the strongest evidence for glycemic benefit among intervention types. Further research is needed to assess non-glycemic outcomes and to study implementation in rural and low-income settings.

Background Increasing access to healthy foods and beverages in disadvantaged communities is a public health priority due to alarmingly high rates of obesity. The Virtual Supermarket Program (VSP) is a Baltimore City Health Department program that uses online grocery ordering to deliver food to low-income neighborhoods. This study evaluates stakeholder preferences and barriers of program implementation. Methods This study assessed the feasibility, sustainability and efficacy of the VSP by surveying 93 customers and interviewing 14 programmatic stakeholders who had recently used the VSP or been involved with program design and implementation. Results We identified the following themes: The VSP addressed transportation barriers and food availability. The VSP impacted customers and the city by including improving food purchasing behavior, creating a food justice “brand for the city”, and fostering a sense of community. Customers appreciated using Supplemental Nutrition Assistance Program (SNAP) benefits to pay for groceries, but policy changes are needed allow online processing of SNAP benefits. Conclusions This evaluation summarizes lessons learned and serves as a guide to other public health leaders interested in developing similar programs. Provisions in the U.S. Department of Agriculture (USDA) Farm Bill 2014 allow for select grocers to pilot online transactions with SNAP benefits. If these pilots are efficacious, the VSP model could be easily disseminated.

Background Many patients have uncontrolled blood pressure (BP) because they are not taking medications as prescribed. Providers may have difficulty accurately assessing adherence. Providers need to assess medication adherence to decide whether to address uncontrolled BP by improving adherence to the current prescribed regimen or by intensifying the BP treatment regimen by increasing doses or adding more medications. Methods We examined how provider assessments of adherence with antihypertensive medications compared with refill records, and how providers’ assessments were associated with decisions to intensify medications for uncontrolled BP. We studied a cross-sectional cohort of 1169 veterans with diabetes presenting with BP ≥140/90 to 92 primary care providers at 9 Veterans Affairs (VA) facilities from February 2005 to March 2006. Using VA pharmacy records, we utilized a continuous multiple-interval measure of medication gaps (CMG) to assess the proportion of time in prior year that patient did not possess the prescribed medications; CMG ≥20% is considered clinically significant non-adherence. Providers answered post-visit Likert-scale questions regarding their assessment of patient adherence to BP medications. The BP regimen was considered intensified if medication was added or increased without stopping or decreasing another medication. Results 1064 patients were receiving antihypertensive medication regularly from the VA; the mean CMG was 11.3%. Adherence assessments by providers correlated poorly with refill history. 211 (20%) patients did not have BP medication available for ≥ 20% of days; providers characterized 79 (37%) of these 211 patients as having significant non-adherence, and intensified medications for 97 (46%). Providers intensified BP medications for 451 (42%) patients, similarly whether assessed by provider as having significant non-adherence (44%) or not (43%). Conclusions Providers recognized non-adherence for less than half of patients whose pharmacy records indicated significant refill gaps, and often intensified BP medications even when suspected serious non-adherence. Making an objective measure of adherence such as the CMG available during visits may help providers recognize non-adherence to inform prescribing decisions.

OBJECTIVE: Patients' self‐management practices have substantial consequences on morbidity and mortality in diabetes. While the quality of patient‐physician relations has been associated with improved health outcomes and functional status, little is known about the impact of different patient‐physician interaction styles on patients' diabetes self‐management. This study assessed the influence of patients' evaluation of their physicians' participatory decision‐making style, rating of physician communication, and reported understanding of diabetes self‐care on their self‐reported diabetes management. DESIGN: We surveyed 2,000 patients receiving diabetes care across 25 Veterans' Affairs facilities. We measured patients' evaluation of provider participatory decision making with a 4‐item scale (Provider Participatory Decision‐making Style [PDMstyle]; α = 0.96), rating of providers' communication with a 5‐item scale (Provider Communication [PCOM]; α = 0.93), understanding of diabetes self‐care with an 8‐item scale (α = 0.90), and patients' completion of diabetes self‐care activities (self‐management) in 5 domains (α = 0.68). Using multivariable linear regression, we examined self‐management with the independent associations of PDMstyle, PCOM, and Understanding. RESULTS: Sixty‐six percent of the sample completed the surveys (N = 1,314). Higher ratings in PDMstyle and PCOM were each associated with higher self‐management assessments (P < .01 in all models). When modeled together, PCOM remained a significant independent predictor of self‐management (standardized β: 0.18; P < .001), but PDMstyle became nonsignificant. Adding Understanding to the model diminished the unique effect of PCOM in predicting self‐management (standardized β: 0.10; P = .004). Understanding was strongly and independently associated with self‐management (standardized β: 0.25; P < .001). CONCLUSION: For these patients, ratings of providers' communication effectiveness were more important than a participatory decision‐making style in predicting diabetes self‐management. Reported understanding of self‐care behaviors was highly predictive of and attenuated the effect of both PDMstyle and PCOM on self‐management, raising the possibility that both provider styles enhance self‐management through increased patient understanding or self‐confidence.