Publications

OBJECTIVE: Cervical cancer is the leading cause of cancer deaths among women in Botswana, yet uptake of cervical screening remains suboptimal. Understanding knowledge and barriers to screening is essential to inform strategies to achieve cervical cancer elimination.

METHODS: We conducted high-risk human papillomavirus (hrHPV) testing and an accompanying cross-sectional survey at health clinics and in the community in South East District, Botswana (February 2022-July 2023). Eligible participants were women aged ≥25 years with an intact cervix and no prior diagnosis of cervical cancer. Interviewer-administered structured questionnaires assessed demographics, prior screening attendance, knowledge of cervical cancer, and perceived barriers to screening. Open-ended responses were thematically categorized. Logistic regression was used to examine factors associated with knowledge and screening barriers.

RESULTS: Of 3000 women screened, 2994 (99.8%) had known HIV status and were included. Median age was 43 years (interquartile range [IQR] 36-51), and 1500 (50.1%) were women with HIV (WWH). Overall, 67.2% (2005/2994) reported prior cervical cancer screening, with substantially higher uptake among WWH than women without HIV (80.0% vs 54.5%, P < 0.001). Knowledge of cervical cancer etiology was limited, with only 27.1% (788/2905) correctly identifying hrHPV as the cause. Younger age, HIV-positive status, higher education, formal employment, and prior screening attendance were independently associated with better knowledge. Among women who had never been screened, the most commonly reported barriers were lack of prioritization (38.3%; 376/981), fear (17.0%; 167/981), lack of awareness (17.0%; 167/981) and service provision issues (12.0%).

CONCLUSION: Despite relatively high screening uptake, important gaps in knowledge and persistent individual- and system-level barriers remain. Strengthening cervical screening delivery through HPV self-collection alongside targeted education, would address current barriers to cervical screening in Botswana.

Abortion doulas support patients who are receiving abortion care. Understanding the abortion doula landscape is critical for patients, clinicians, doulas, and those interested in expanding programs for doula support. We aimed to describe the state of US-based abortion doula programs through a mapping review of the grey literature, documenting programs' characteristics from their online presence (websites, Facebook, Instagram, X). We identified 17 active abortion doula programs. In addition, we identified 30 programs which appeared either to be inactive or to not provide abortion support, primarily in states with post-Dobbs abortion bans. Most active abortion doula programs are community-based, volunteer-run, and free for patients. Three doula programs have partnerships with local clinics; three clinics have in-house doula programs. Most train their own doulas. Most US-based abortion doula programs independently provide community-based, no-cost, volunteer doula services.

BACKGROUND: Black-White inequities in severe maternal morbidity in the United States are extreme and growing. Maternal safety bundles (MSBs) have been associated with closing racial equity gaps in maternal health in some states. The objective of this study was to explore clinician perspective and experiences of implementing an Equity maternal safety bundle across five hospitals in Massachusetts to address inequities in perinatal care and birth outcomes.

METHODS: Focus group discussions and interviews were conducted in Fall 2022 and Fall 2023 (before and after Equity MSB implementation) among obstetric nurses, resident physicians, and attending physicians. Discussions were facilitated using a semi-structured guide developed using the Consolidated Framework for Implementation Research (CFIR). Transcripts were independently coded by two analysts using NVivo 14. A codebook was developed using CFIR for deductive coding. We added inductive codes as appropriate. We calculated Cohen's kappa coefficients to assess interrater reliability. Themes were generated through an iterative process and compared across study time points.

RESULTS: Fifteen clinicians participated at each time point with similar distributions across race, ethnicity, gender, and profession. Seven themes emerged from these interviews: 1) the importance of leadership support to prioritize equity, 2) a culture of equity as a facilitator for implementation, 3) the need for improved processes for self-reported race, ethnicity, and language data collection, stratification, and dissemination, 4) staff, time, and funding as necessary resources, 5) the need for an early focus on staff education, 6) existing siloes between physicians and nurses and exclusion of trainees as barriers to implementation, and 7) differences between an Equity-MSB and other MSBs.

CONCLUSIONS: Leadership prioritization of equity and a culture of equity emerged as facilitators to successful implementation of elements of the Equity MSB. Challenges identified included resistance to change among colleagues, limited resources, and clinician siloes. When compared to previously implemented MSBs, participants found that leadership made this work a priority. As future hospital teams embark on implementing equity-focused action, these known facilitators and barriers should be considered and addressed during the pre- and early-implementation phases.

Racial and ethnic health inequities are pervasive in the US healthcare system and affect individuals at all stages of life. These inequities are the result of racism and not due to biology. Racism is a multi-level system that embodies institutional, structural, interpersonal, and internalized racism. Racism in the healthcare setting creates hierarchies of power based on the social construct of race that impact opportunity, access, quality, and experiences of minoritized individuals. Most interventions to address health inequity in the healthcare setting target individual-level racism, but this has largely been ineffective in closing the equity gap. Few interventions have been developed to target structural and institutional racism. This may in part be due to a lack of healthcare-specific tools that can identify targets for intervention at the structural and institutional level. In this article, we report the development of the Healthcare Racial Justice Assessment Tool (HC-RJAT), a novel tool specifically designed to identify modifiable loci of structural and institutional racism within the healthcare setting to guide equity-focused interventions.

INTRODUCTION: There is a shortage of individuals trained in using quantitative methods in biomedical research in sub-Saharan Africa (SSA). Improving public health in SSA requires new ways to promote quantitative knowledge and skills among faculty in biomedical research and better-integrated network systems of support.

METHODS: We describe the development, implementation, and evaluation of an innovative faculty training and support program in SSA from December 2017-June 2020, using courses in monitoring and evaluation, data management, and complex surveys as prototypical examples. Indicators were selected to follow the 4 levels outlined in the Kirkpatrick evaluation model: reaction, learning, behavior, and results. We used survey data from faculty fellows and students and reported median change and interquartile ranges (IQR).

RESULTS: The training program created an international community of 26 faculty members working collaboratively to lead the training of 3 quantitative methods courses. The program increased faculty members' knowledge of the course content (median increase 17 percentage points [IQR: 0, 20]). Faculty members, in turn, trained 380 students at institutions of higher education in 8 SSA countries (Botswana, Ethiopia, Ghana, Nigeria, Rwanda, South Africa, Tanzania, and Uganda).

CONCLUSION: The program relied on collaborative funding from participating institutions and focused on individual capacity-strengthening. In the future, the program will be scaled to include other emerging areas, such as data science, will integrate institutional support and feedback, and will move some of the training and mentoring activities to an online platform. Finally, to ensure that faculty have both improved confidence and improvement in competence, in future iterations, the program will include competency evaluation at the start and end and pair fellows who need additional training with those who excelled to co-teach.

BACKGROUND: Birth doula services in the United States are increasingly covered by insurance and sought out by patients. To be effective team members on labour and delivery (L&D), it is critical that medical students understand doulas' role and how to collaborate with doulas in patient care.

APPROACH: To this end, we developed an L&D simulation for students to practice working with doulas. Preclinical medical students participated with an obstetrician, anesthesiologist, nurse and doula in a simulated patient birth and debrief.

EVALUATION: A descriptive evaluation was conducted via presimulation and postsimulation surveys asking students to evaluate their comfort "caring for a patient with a doula" and understanding of the "doula [role] during a delivery" on a 7-point scale. Presimulation to postsimulation comparisons were done with linear regressions with clustering. This project received a nonhuman subjects research determination. In total, 255 students participated across 2 years; 212 students completed surveys. Of students who completed presimulation surveys (N = 201), 17.8% had previous L&D experience. Participating in the simulation significantly increased both students' comfort collaborating with a doula (3.1 points) (95% confidence interval [CI]: 2.9-3.4) and their understanding of the doula role (3.2 points) (95% CI: 2.9-3.5). Presimulation, students with prior L&D experience had higher understanding of doulas' role than those without experience (0.70 points, 95% CI: 0.09-1.3).

IMPLICATIONS: Including birth doulas in obstetric simulations is an effective method to improve preclinical medical students' awareness and understanding of the doula role, providing an important opportunity to improve L&D collaboration and patient care.

BACKGROUND: Qualified language service providers (QLSPs)-professional interpreters or multilingual clinicians certified to provide care in another language-are critical to ensuring meaningful language access for patients. Designing patient-centered systems for language access could improve quality of pregnancy care.

OBJECTIVE: We synthesized and identified gaps in knowledge about communication preferences during pregnancy care among patients with Spanish primary language.

METHODS: We performed a scoping review of original research studies published between 2000 and 2022 that assessed communication preferences in Spanish-speaking populations during pregnancy care. Studies underwent title, abstract, and full-text review by three investigators. Data were extracted for synthesis and thematic analysis.

RESULTS: We retrieved 1,539 studies. After title/abstract screening, 36 studies underwent full-text review, and 13 of them met inclusion criteria. Two additional studies were included after reference tracing. This yielded a total of 15 studies comprising qualitative (n = 7), quantitative (n = 4), and mixed-methods (n = 4) studies. Three communication preference themes were identified: language access through QLSPs (n = 7); interpersonal dynamics and perceptions of quality of care (n = 9); and information provision and shared decision-making (n = 8). Although seven studies reported a strong patient preference to receive prenatal care from Spanish-speaking clinicians, none of the included studies assessed clinician Spanish language proficiency or QLSP categorization.

CONCLUSIONS: Few studies have assessed communication preferences during pregnancy care among patients with primary Spanish language. Future studies to improve communication during pregnancy care for patients with primary Spanish language require intentional analysis of their communication preferences, including precision regarding language proficiency among clinicians.

OBJECTIVES: Endometrial cancer is a collection of heterogeneous histologies and molecular subtypes with different risk profiles. High-risk endometrial cancer surveillance regimens vary amongst providers. The National Comprehensive Cancer Network (NCCN) recommends symptom and exam-based surveillance for all endometrial cancers after remission, regardless of cancer stage and histology. Our objective was to identify the first method of detection of recurrence in high-risk endometrial cancers and examine disease recurrence and treatment patterns.

METHODS: A retrospective review of patients diagnosed with high-risk endometrial cancer between November 2013 and February 2020 was conducted at a large academic institution. High-risk endometrial cancers were classified by histology and pathologic stage and were categorized by primary method of detection.

RESULTS: Two hundred and twenty-nine patients were identified with high-risk endometrial cancer, 63 (28 %) of whom had a recurrence. Most recurrences were first detected with routine imaging in 31 patients (49.2 %) and symptom surveillance in 24 patients (38.15 %). Regardless of the detection method, most patients underwent systemic treatment. The average survival after recurrence was 2.0 years in the imaging cohort and 1.6 years in the non-imaging surveillance cohort.

CONCLUSIONS: The most common site of recurrence in our cohort of high-risk endometrial cancer was in the lung, and most recurrences were identified with asymptomatic imaging. Though there was no statistically significant difference between the survival of those who underwent imaging surveillance vs. standard of care, there was a trend toward survival that deems further exploration with a larger cohort.

INTRODUCTION: The impact of doula care on birth outcomes is well-established; however, doula support remains underutilized. Identifying barriers and facilitators to implementation is integral as the demand for doula care increases. The primary objective of this study was to examine doula program implementation across hospitals and payers at varying stages of implementation.

METHODS: Representatives from 4 hospitals and 2 payers participated in focus group discussions. The doula programs were categorized as anticipated, initial, and advanced implementation statuses. Coding and thematic analysis were conducted using a deductive application of the Consolidated Framework for Implementation Research.

RESULTS: There were 20 participants across 5 focus group discussions. Participants were mostly female, and nearly all had worked at their organization for at least 2 years. Salient themes shared across participants included valuing internal outcome data or peer-reviewed literature to support doula care as well as anecdotal stories; the reality of the resource-intensive nature of doula care implementation that goes beyond funding for doulas; and both the need for individual champions for change, such as midwives, and a supportive organizational culture that values health equity.

DISCUSSION: The findings of this study highlight 3 contextual aspects that should be considered when implementing doula programs. These recommendations include: (1) use of a combination of research evidence and anecdotes when eliciting stakeholder support; (2) consideration of resources beyond funding such as program implementation support; (3) critical evaluation of organizational culture as a primary driver influencing the implementation of doula care. The future of the doula workforce in United States hospitals rests on the crux of intentional buy-in from hospital administration and clinical providers as well as the availability of requisite resources.

INTRODUCTION: High-quality health systems rely on care that centers on patient preferences. Realization of patient preferences can improve the birth experience. However, in the dynamic setting of birth, birth preferences can diverge from what is medically indicated. Through studying women and birthing peoples' experiences of unplanned labor procedures, we aimed to identify ways in which practitioners can support women and birthing people through unexpected or unwanted aspects of their delivery. Specifically, we focused on labor induction.

METHODS: In one large US academic center, women and birthing people participated in prenatal and postpartum surveys regarding their desires, expectations, and experiences of labor induction. From April to November 2021, participants were eligible if they showed discordance between having labor induction and whether it was initially wanted or expected. Interviews focused on attitudes toward birth preferences and outcomes, with attention to discordances. We analyzed interviews through a modified grounded theory approach.

RESULTS: Of 22 participants, our sample was predominantly white (91%). Participants in this sample reported discordance between wanting and experiencing (73%) and/or expecting and experiencing (54%) an induction. We identified two themes: "Discordance without mitigation is perceived as a negative experience" and "Practitioner interaction can buffer against negative experience" which includes three ways in which participants prefer support in instances of discordance: preparation, communication, and care and comfort. These methods of support foster patient autonomy and can lead to positive patient experiences.

CONCLUSIONS: While medical systems should work to support patient preferences, our results suggest that patients can still have positive birth experiences, even when preferences are not fulfilled. Early practitioner preparation, positive communication, and responsive care and comfort may help to improve patient birth experience when challenges arise.