Healthcare Sites Research Articles

“I Don’t Really Know What Diabetes Is”: A Qualitative Study Exploring the Experiences of Aboriginal and Torres Strait Islander Young People Aged 10 to 25 Years Living With Type 2 Diabetes in Northern and Central Australia

ObjectiveOur aim in this study was to gain an understanding of the experiences of Aboriginal and Torres Strait Islander young people aged 10 to 25 years with type 2 diabetes (T2D) living in Northern and Central Australia. MethodsIn this qualitative study, we explored participants’ experiences of T2D using a social constructionist epistemology and a phenomenologic methodology. Twenty-seven young people participated in semistructured in-depth interviews from 4 primary health-care sites. ResultsThree major constructs emerged. Young people experienced a normalization–shame paradox in response to their diagnosis (partly related to that “everyone has diabetes,” as well as the fear that friends “might judge [me]”), had suboptimal levels of understanding of T2D (“I don’t really know what diabetes is. I just need somebody to explain to me a bit more”) and experienced multiple barriers inhibiting their T2D management. Barriers included complex lives (“I have a rheumatic heart disease […] then they told me that I have diabetes…I have two things”) and the availability of support (“[I] talk to my mum…I talk to my aunty too…I don’t talk to anyone else”). Successful management requires support from health professionals and family and includes strengthening social networks and educational opportunities. ConclusionsOur findings reinforce the need for alternative support systems tailored to the specific needs of young Aboriginal and Torres Strait Islander people with T2D. Enhanced models of care must be codesigned with young people and their communities and include a focus on shifting norms and expectations about youth T2D to reduce diabetes stigma and broaden social support and consider the delivery of health information in youth-friendly environments.

The Atlas Context Data Repository: A Feasible, Acceptable, and Useful Prototype for Context Data Collection and Future Predictive Analysis.

Evidence from health care and other fields indicates that context matters for successful implementation of quality improvement initiatives. Most context assessment frameworks and tools are evidence-informed; that is, based on literature and expert opinion/consensus. Quantitative evidence is lacking on which aspects of context most strongly predict implementation success. Implementers need this evidence to prioritize contextual factors for assessment and action. The Atlas Initiative developed a prototype of surveys and data collection processes for populating the Atlas Context Data Repository, a large database that will enable statistical analyses of the relationship between context and implementation success. The prototype was piloted with eight US health care sites to assess its feasibility, acceptability, and utility for individual implementers and for use at scale. The researchers collected and analyzed quantitative data from the repository surveys, shared context assessment reports with sites, interviewed sites about their experiences, and held internal team debriefs. Sites found the Atlas prototype feasible and acceptable to implement and the context assessment reports useful for understanding their strengths and challenges. The Atlas Initiative successfully recruited repository participants and supported survey administration. The sample data, although too small to make predictive inferences, had reasonable distributions and low missingness. The results indicate that the Atlas Context Data Repository can be feasibly implemented at scale with minor modifications to the prototype, that the repository database can support future statistical analyses when it has more data, and that participation in the repository is valuable and worthwhile for sites.

Health Workers Readiness for Implementation of a Mobile Pregnancy Monitoring System in Primary Health Care: A Cross-Sectional Study

Purpose: The study aims to describe factors related to the readiness of health workers with respect to implementation of a mobile Pregnancy Monitoring System in Primary Health Care (PHC) sites of the South Tangerang District in Banten Province, Indonesia using a socio-technical approach. 
 Methods: A cross-sectional survey design was used among respondents who were involved during the antenatal care process. The participants (n=210) completed the questionnaire that measured information needs regarding the socio-technical aspect of readiness and factors affecting the readiness. The data was analysed using logistic regression analysis. 
 Result: The findings of this study showed that the majority of the health workers who were involved in the antenatal care process were ready to implement the mobile pregnancy monitoring system. Having social media (P= .013) and willingness (P= .007) to be involved in IT implementation are associated with IT readiness, while there is no significant association between demographic factors to the readiness of the health workers.
 Conclusion: Since there is no connectivity between the demographic factors to readiness, thus the supportive factors such as having a social media and willingness are easier to resolve than inferring from the demographic factors.

IAEA support to the radiation protection of patients in the time of the COVID-19 global pandemic.

The IAEA contribution to the radiation protection of patients during the global COVID-19 pandemic included a webinar on the use of CT and optimization for COVID-19 pneumonia, a survey with 137 responses from 84 sites across five continents, and a study on the CT utilization, protocols and patient doses with data from 62 healthcare sites from 34 countries. This paper outlines the main results of these efforts, which have been presented in the scientific literature and in several national trainings and international meetings.

Adjusting the Canadian Healthcare System to Meet Newcomer Needs.

Newcomers’ ability to access healthcare can be impacted by cultural, religious, linguistic, and health status differences. A variety of options are available to support the development of healthcare systems to equitably accommodate newcomers, including the use of basic English and other languages in public health information, engagement with immigrant communities to advise on program development, offering culturally competent health services, interpretation services, and through creating space to collaborate with traditional practitioners. This study employed in-depth interviews with newcomer families from the Healthy Immigrant Children Study that had been living in Regina or Saskatoon, Saskatchewan, Canada, for less than 5 years, as well as with healthcare providers and immigrant service providers to understand how to improve healthcare services. Analysis of participant quotes related to accessible healthcare services revealed five main themes: (1) responsive, accessible services, (2) increasing cultural competence, (3) targeted newcomer health services, (4) increasing awareness of health services, and (5) newcomer engagement in planning and partnerships. An accessible healthcare system should include primary healthcare sites developed in partnership with newcomer service organizations that offer comprehensive care in a conveniently accessible and culturally responsive manner, with embedded interpretation services. The Saskatchewan healthcare system needs to reflect on its capacity to meet newcomer healthcare needs and strategically respond to the healthcare needs of an increasingly diverse population.

Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis.

IntroductionMen are missing along the HIV care continuum. However, the estimated proportions of men in sub‐Saharan Africa meeting the UNAIDS 95‐95‐95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95‐95‐95 goals across studies in sub‐Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement.MethodsWe systematically searched PubMed and Embase for peer‐reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95‐95‐95 goal in sub‐Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion‐Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta‐synthesis.Results and discussionWe screened 14,896 studies and included 129 studies in the meta‐analysis, compiling data over the data collection period. Forty‐seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41–0.58; range, 0.09–0.97]) or not being on treatment (0.58 [95% CI, 0.51–0.65; range, 0.07–0.97]), while over three‐quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77–0.81; range, 0.39–0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta‐synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty.ConclusionsPsychosocial and systems‐level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.

Intelligent Clinical Decision Support.

Early recognition of pathologic cardiorespiratory stress and forecasting cardiorespiratory decompensation in the critically ill is difficult even in highly monitored patients in the Intensive Care Unit (ICU). Instability can be intuitively defined as the overt manifestation of the failure of the host to adequately respond to cardiorespiratory stress. The enormous volume of patient data available in ICU environments, both of high-frequency numeric and waveform data accessible from bedside monitors, plus Electronic Health Record (EHR) data, presents a platform ripe for Artificial Intelligence (AI) approaches for the detection and forecasting of instability, and data-driven intelligent clinical decision support (CDS). Building unbiased, reliable, and usable AI-based systems across health care sites is rapidly becoming a high priority, specifically as these systems relate to diagnostics, forecasting, and bedside clinical decision support. The ICU environment is particularly well-positioned to demonstrate the value of AI in saving lives. The goal is to create AI models embedded in a real-time CDS for forecasting and mitigation of critical instability in ICU patients of sufficient readiness to be deployed at the bedside. Such a system must leverage multi-source patient data, machine learning, systems engineering, and human action expertise, the latter being key to successful CDS implementation in the clinical workflow and evaluation of bias. We present one approach to create an operationally relevant AI-based forecasting CDS system.

Integrated Behavioral Health Care in Viet Nam: Examples from the Hanoi Bach Mai Hospital of Patients with Hypertension

Objectives: Behavioral conditions contribute to poor clinical outcomes and are not routinely addressed in medical settings in Viet Nam. Few studies focus on the level of integrated care in clinics, the provider ratings of the prevalence of behavioral conditions, the need for a behavioral health consultant (BHC), and patient health risk assessments (HRAs) in Viet Nam. To fill these research gaps, this study aims to explore the level of behavioral health integration in primary care clinics, the provider perceived prevalence of behavioral problems, the need for an expert behavioral health consultant on the primary care team, and the health risks for patients in Viet Nam. Methodology: This study collected first-hand survey data from two healthcare sites, 41 service providers, and 199 patients in Hanoi, Viet Nam. Regression analyses were conducted to examine the relationship between HRA behavioral conditions and each of the biometric health risk factors. Results: The healthcare site and provider survey results showed low levels of integrated health services, provider perceptions of the moderate prevalence of common behavioral conditions, and the need for a BHC to assist in care. In addition, the patient’s HRA results showed an elevated risk of sleep apnea, fruit and vegetable intake, tobacco, alcohol use for men, and poor health literacy. Conclusion: The level of integrated care services is low in Viet Nam, the need for the providers to have a BHC to assist in treatment is moderate, and the patients reported elevated health risks in several areas. The findings demonstrated a pressing need for the development of integrated behavioral health care services in Viet Nam.

Generating real-world data from health records: design of a patient-centric study in multiple sclerosis using a commercial health records platform.

ObjectiveThe FlywheelMS study will explore the use of a real-world health record data set generated by PicnicHealth, a patient-centric health records platform, to improve understanding of disease course and patterns of care for patients with multiple sclerosis (MS).Materials and MethodsThe FlywheelMS study aims to enroll 5000 adults with MS in the United States to create a large, deidentified, longitudinal data set for clinical research. PicnicHealth obtains health records, including paper charts, electronic health records, and radiology imaging files from any healthcare site. Using a large-scale health record processing pipeline, PicnicHealth abstracts standard and condition-specific data elements from structured (eg, laboratory test results) and unstructured (eg, narrative) text and maps these to standardized medical vocabularies. Researchers can use the resulting data set to answer empirical questions and study participants can access and share their harmonized health records using PicnicHealth’s web application.ResultsAs of November 24, 2020, more than 4176 participants from 49 of 50 US states have enrolled in the FlywheelMS study. A median of 200 pages of records have been collected from 14 different doctors over 8 years per participant. ion precision, established through inter-abstractor agreement, is as high as 97.8% when identifying and mapping data elements to a standard ontology.ConclusionUsing a commercial health records platform, the FlywheelMS study is generating a real-world, multimodal data set that could provide valuable insights about patients with MS. This approach to data collection and abstraction is disease-agnostic and could be used to address other clinical research questions in the future.

Practices of waste management in health care facilities in Nepal's Biratnagar metropolitan city

Biratnagar is a medical referral centre with tertiary health care in Eastern Nepal. The city population is 202,061, according to the 2011 census. There are 35 Health Care Facilities (HCFs) in the city as of 2014. There are 7 HCFs, 2 non-governmental HCFs, and 26 private HCFs. In 2014, the District Public Health Office Morang, the Biratnagar municipality, and the private sector collaborated to check Biratnagar's health care waste management. Investigators performed a semi-structured questionnaire and checklists while visiting health care sites. According to the survey results, 10% of HCFs use incinerators. 80% of HCFs separate their garbage, 60% use needle destroyer machines, and 50% use coloured dustbins to separate different sorts of medical waste. The bed occupancy rate is 78%. Every day, one sweeper looks for 6.66 beds. Even 10% of HCFs let their waste out in the open. HCFs do not have enough capacity for waste disposal facilities. Thus, HCFs pay the municipality Rs. 1500- 15000 a month to have the facility's waste removed. In the municipality tractor, they are hauling medical garbage and home rubbish. As a result, the city discharges health care waste with household waste in the Singhiaya River. These actions endanger public health. Biratnagar city generates 118 Kgs of hazardous health care waste daily, necessitating immediate treatment. Biratnagar Municipality should collaborate with partners to develop a short and long-term strategy.

Advancing State and Local Home Modification Practice and Policy: Findings From Aging Network Surveys

Home modification (HM) can promote older adults’ functioning as their needs change, reduce fall risks, and support caregivers. A supportive home environment is increasingly important as homes become healthcare delivery sites for home and community-based services (HCBS). HM is funded and administered by disparate agencies, often hindering access to HM services for at-risk older adults who need them the most. The Aging Network (State Units on Aging (SUAs), Area Agencies on Aging (AAAs), and Title VI organizations serving Native American older adults) plays an important but not well understood role in HM. To address this lack of research, the USC Leonard Davis School of Gerontology, ADvancing States, and the National Association of Area Agencies on Aging in cooperation with Scripps Gerontology Center conducted three national surveys, with support from the Administration for Community Living: 1) directors of the 56 SUAs with an 89% response rate; 2) directors of the 618 AAAs with a 79% response rate; and 3) directors of 276 Title VI programs with an 84% response rate. Exemplary practices included HM advocacy through interagency coalitions; state and local plan priority setting; creative HM financing with housing, disability, and health care sectors, including partnerships with Medicaid agencies; and integration of HMs into state and local HCBS, including nursing home transition and caregiver support programs. Findings on the types of HM activities, service delivery barriers, funding sources, collaborations, and targeted populations will inform HM policy and practice for the Aging Network’s critical state and local agencies serving low-income older adults.

Successes and Lessons Learned From Age-Friendly Community Collaborations: Baystate Health GWEP

Baystate is the largest health system in Western Massachusetts with 4 hospitals, 3 Community Health Centers (CHCs) and a large primary care network. Baystate Medical Center (BMC) is in Springfield, Massachusetts. BMC and the CHCs were the first health care sites nationally to be recognized by the Institute for Healthcare Improvement as “Committed to Care Excellence” in the age friendly movement. Collaboration with a city-wide coalition of community-based organizations led to simultaneous recognition of Baystate as “age friendly” and recognition of the city as both dementia and age friendly. The 3 awards were presented at a Springfield senior center with media coverage and the participation of the mayor and other political leaders. This collaboration persists and the GWEP and coalition partners continue to participate in multiple joint educational and community outreach projects. As a result, the city coalition has added health care to its initial focus on housing and transportation.

CHEST CT USAGE IN COVID-19 PNEUMONIA: MULTICENTER STUDY ON RADIATION DOSES AND DIAGNOSTIC QUALITY IN BRAZIL.

We assessed variations in chest CT usage, radiation dose and image quality in COVID-19 pneumonia. Our study included all chest CT exams performed in 533 patients from 6 healthcare sites from Brazil. We recorded patients’ age, gender and body weight and the information number of CT exams per patient, scan parameters and radiation doses (volume CT dose index—CTDIvol and dose length product—DLP). Six radiologists assessed all chest CT exams for the type of pulmonary findings and classified CT appearance of COVID-19 pneumonia as typical, indeterminate, atypical or negative. In addition, each CT was assessed for diagnostic quality (optimal or suboptimal) and presence of artefacts. Artefacts were frequent (367/841), often related to respiratory motion (344/367 chest CT exams with artefacts) and resulted in suboptimal evaluation in mid-to-lower lungs (176/344) or the entire lung (31/344). There were substantial differences in CT usage, patient weight, CTDIvol and DLP across the participating sites.

18. Global Surveillance of Clostridioides difficile Demonstrates High Prevalence in Non-Healthcare Settings

Background Clostridioides difficile is a Gram-positive, spore-forming, toxin-producing organism that is the leading cause of healthcare-associated infections. However, past studies have isolated C. difficile spores from the community, suggesting an environmental reservoir that may play a role in transmission. This study aimed to examine the prevalence and strain types of C. difficile isolated from the United States (US) and internationally.MethodsFrom 2014 to 2017, environmental swabs were collected from public areas, healthcare settings, and shoe soles. Samples were considered positive for C. difficile following growth on CCFA plates and confirmatory PCR testing for toxin genes and fluorescent PCR ribotyping (RT). The rate of C. difficile positivity and associated RT distribution were compared between settings, including shoe soles which were investigated for their potential role in environmental transmission.ResultsA total of 11,986 unique isolates were obtained primarily from the US (n=11,002; 92%) in addition to 11 other countries including Taiwan (n=200) and India (n=187). Samples were categorized as being from outdoor environments (n=2,992), private residences (n=2,772), shoe soles (n=1,420), public buildings (n=1,104) or acute care settings (n=3,698). Worldwide C. difficile sample positivity was 26% and was similar between US and non-US sampling sites. In the US, private residences (26.2%) and outdoor environments (24.1%) had the highest positivity rate compared to public buildings (17.2%). In a Texas sub-analysis (n=8,571), positivity rates were highest from outdoor samples (27%) and were similar between private residences (24%) and healthcare buildings (24%). The most prevalent RTs overall were F014-020 (16.4%), F106 (14.9%), and FP310 (11%). Shoe soles had the highest positivity rate (45%) with similar RT distribution between shoe soles and environmental samples.ConclusionUsing a worldwide sample, 26% of environmental samples tested positive for toxigenic C. difficile strains from healthcare and non-healthcare sites. Community stewardship efforts will be needed to reduce the risk of CDI in vulnerable patients. Shoe sole sampling may be an ideal surveillance tool to test for emerging epidemic strains.Disclosures Kevin W. Garey, Pharm.D., M.S., FASHP, Summit Therapeutics (Research Grant or Support)

Implementation Strategies to Improve Engagement With a Multi-Institutional Patient Portal: Multimethod Study.

BackgroundComprehensive multi-institutional patient portals that provide patients with web-based access to their data from across the health system have been shown to improve the provision of patient-centered and integrated care. However, several factors hinder the implementation of these portals. Although barriers and facilitators to patient portal adoption are well documented, there is a dearth of evidence examining how to effectively implement multi-institutional patient portals that transcend traditional boundaries and disparate systems.ObjectiveThis study aims to explore how the implementation approach of a multi-institutional patient portal impacted the adoption and use of the technology and to identify the lessons learned to guide the implementation of similar patient portal models.MethodsThis multimethod study included an analysis of quantitative and qualitative data collected during an evaluation of the multi-institutional MyChart patient portal that was deployed in Southwestern Ontario, Canada. Descriptive statistics were performed to understand the use patterns during the first 15 months of implementation (between August 2018 and October 2019). In addition, 42 qualitative semistructured interviews were conducted with 18 administrative stakeholders, 16 patients, 7 health care providers, and 1 informal caregiver to understand how the implementation approach influenced user experiences and to identify strategies for improvement. Qualitative data were analyzed using an inductive thematic analysis approach.ResultsBetween August 2018 and October 2019, 15,271 registration emails were sent, with 67.01% (10,233/15,271) registered for an account across 38 health care sites. The median number of patients registered per site was 19, with considerable variation (range 1-2114). Of the total number of sites, 55% (21/38) had ≤30 registered patients, whereas only 2 sites had over 1000 registered patients. Interview participants perceived that the patient experience of the portal would have been improved by enhancing the data comprehensiveness of the technology. They also attributed the lack of enrollment to the absence of a broad rollout and marketing strategy across sites. Participants emphasized that provider engagement, change management support, and senior leadership endorsement were central to fostering uptake. Finally, many stated that regional alignment and policy support should have been sought to streamline implementation efforts across participating sites.ConclusionsWithout proper management and planning, multi-institutional portals can suffer from minimal adoption. Data comprehensiveness is the foundational component of these portals and requires aligned policies and a key base of technology infrastructure across all participating sites. It is important to look beyond the category of the technology (ie, patient portal) and consider its functionality (eg, data aggregation, appointment scheduling, messaging) to ensure that it aligns with the underlying strategic priorities of the deployment. It is also critical to establish a clear vision and ensure buy-ins from organizational leadership and health care providers to support a cultural shift that will enable a meaningful and widespread engagement.

Real-world screening for diabetes in early pregnancy: Improved screening uptake using universal glycated haemoglobin

AimsTo improve perinatal outcomes, screening for hyperglycaemia using 75 g oral glucose tolerance test (OGTT) is recommended for all pregnant women at 24–28 weeks gestation (routine), and earlier if high-risk. Screening coverage for remote and Aboriginal Australian women is less than ideal. This study examined OGTT completion (early and routine) by women from rural and remote Western Australia compared with early glycated haemoglobin (HbA1c). MethodsIn 2015–2018, 27 primary health care sites recruited 600 (233 Aboriginal) women aged ≥16-years, without pre-existing diabetes, who delivered >30-weeks gestation. All women presenting <20-weeks gestation (541) were offered an early study HbA1c. Early OGTTs were requested at the discretion of the local clinician, with routine OGTT offered at 24–28 weeks. ResultsHbA1c uptake was high (85.7% Aboriginal, 86.4% non-Aboriginal); OGTT completion in Aboriginal women was low (early OGTT: 38.6% v 69.6% non-Aboriginal, P < 0.001; routine OGTT: 44.5% v 84.7% non-Aboriginal, P < 0.001). Aboriginal women with both early tests had HbA1c completed 3-weeks prior to OGTT (9.6 ± 3.5 v 12.5 ± 3.5 weeks gestation, P < 0.001). ConclusionsUniversal early pregnancy HbA1c appears feasible as an early screening test for women at risk of hyperglycaemia in pregnancy and would expedite and increase screening in Aboriginal women compared to an early OGTT.

Spatial analysis and modelling for primary healthcare site selection in Midnapore town, West Bengal.

Unprecedented and chaotic growth of cities results in reducing open spaces and water bodies, worsening infrastructure facilities and changes in ecological morphology. This unregulated growth of the urban population led to uneven distribution of urban amenities, facilities and healthcare services. Considering this, the study aimed to draw attention to the existing spatial pattern of healthcare facility centres as well as to find out the possible sites for the provision of healthcare facility centres in the municipal ward (micro-scale) of Midnapore town. This prototype study was conducted using Analytical Hierarchy Process (AHP) and Ordinary Least Square (OLS) evaluation model based on various criteria through Arc GIS environment. The findings indicate that the spatial distribution patterns of existing public healthcare centres were significantly dispersed. Weights based on a set of criteria were calculated by AHP and OLS algorithm and generated suitability evaluation maps classified from 1 (poor suitable) to 4 (most suitable). According to the employed criteria in this study unveil those existing hospitals and primary healthcare centres have not been located in the appropriate locations. The model is found to be valid for the given study area and there is no significant difference between AHP and OLS results. Further, it can be used for preparing the suitability map for the other areas with similar geo-environmental conditions for the proviso of healthcare services as well as will be most effective in preventing disease progression and reducing healthcare inequality on a large scale.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10708-021-10528-w.

A geospatial approach for site suitability and accessibility for healthcare services in Bankura district, West Bengal, India

Healthcare site selection assumes an imperative part in healthcare development and management. From part of the public authority, proper medical site selection will help the distribution of clinical assets, coordinating with the arrangement of medical care with the social and economic demands, organizing the metropolitan and rural healthcare administration advancement, and facilitating social logical inconsistencies. Site suitability analysis is a variety of analysis utilized in GIS to work out the simplest place or site for one thing. The main objective of the current study was to select a site for new healthcare services with geospatial technologies to intermix spatial and non-spatial data to create a weighted result. The current study had been done into three phases, where many processes are intermixed into a single phase. In the first phase of analysis, distance, density, and proximity were mapped to seek out poor and lower accessible areas of healthcare from existing healthcare. To selecting new healthcare sites, four-factor criteria (Buffer around road and rail, land use land cover and buffer around settlement,) and some constrain criteria considered in the second phase of analysis. Finally, the shortest network path analysis has been done in the third phase to determine the shortest and best route from selected healthcare sites towards district medical college. The current study presents some suitable sites in the poor and inaccessible areas of the district. This study will be very helpful for the decision support system of healthcare management in the future.

Newcomer challenges with accessing healthcare services in Saskatchewan, Canada

Newcomers experience a variety of barriers to healthcare services. The study objective is to identify newcomers’ healthcare barriers. During 2014-2015, we conducted in-depth interviews with service providers, and newcomer parents who had been in Saskatchewan for under 5 years. Primary themes include: 1) navigation difficulty, 2) limited awareness, 3) language, 4) interpretation and translation, 5) health benefits, 6) service limitations and stigma, 7) gender and cultural concerns, 8) health attitudes and beliefs, and 9) work demands. The results exposed service gaps and suggest options to improve access to healthcare. Consideration should be given to the development of formal processes to ensure the provision of information concerning healthcare and health benefit programs, as well as responsive healthcare services, including convenient primary healthcare sites that offer comprehensive care in a culturally responsive manner with embedded interpretation services to ensure that the Saskatchewan healthcare system does not perpetuate or create health disparities.

United States nurses' experiences during the COVID-19 pandemic: A grounded theory.

The objective of this study was to explore nurses' experiences and perceptions at selected United States (U.S.) healthcare sites during the COVID-19 pandemic. The COVID-19 pandemic brought rapid changes to the healthcare community. While a few studies have examined the early pandemic experiences of nurses in China and Europe, nurses' experiences across the United States have remained relatively underexplored. A qualitative study design was used. Using a constructivist grounded theory methodology and methods, we conducted eight focus groups across four hospital sites in the eastern, midwestern and western United States. Registered nurses with a minimum of six months' experience working in all clinical specialties were eligible. Forty-three nurses participated. Data were analysed iteratively using the constant comparative method. The COREQ guidelines supported the work and reporting of this study. The nurses experiencing a pandemic (NEXPIC) grounded theory emerged positing associations between four interrelated themes: Challenges, Feelings, Coping and Ethics. Nurses reported Challenges associated with changes in the work environment, community and themselves. They expressed more negative than positive feelings. Nurses coped using self-care techniques, and teamwork within the healthcare organisation. Moral dilemmas, moral uncertainty, moral distress, moral injury and moral outrage were ethical issues associated with nurses' Challenges during the pandemic. Moral courage was associated with positive Coping. Awareness of frontline nurses' complex and interrelated needs may help healthcare organisations protect their human resources. This new theory provides preliminary theoretical support for future research and interventions to address the needs of frontline nurses. Nurses face added distress as frontline at-risk caregivers. Interventions to promote nurses' ability to cope with personal and professional challenges from the pandemic and address ethical issues are needed to protect the nursing workforce. This study offers a new substantive theory that may be used to underpin future interventions.