Mixed Methods Explanatory Sequential Study Research Articles

New Insights Into Predictors of Antihypertensive Adherence

Abstract: Background: Low adherence to treatment is the most common cause of uncontrolled hypertension. Evidence suggests that illness perceptions and the physician-patient relationship may have a combined effect on treatment adherence. Aims: We investigated the roles of illness perceptions and the physician-patient relationship in medication and lifestyle modification adherence, and explained them using patients’ experiences with essential hypertension.Method: In this mixed methods explanatory sequential study, we used questionnaires to assess illness perceptions, the physician-patient relationship, and adherence to medication and lifestyle modification guidance ( N = 112) in the first quantitative phase. Based on the results of regression analyses, the second qualitative phase was planned. We collected data from three patients through interviews, observations and journals, and conducted within-case and cross-case analyses. Finally, we integrated quantitative and qualitative findings. Results: The physician-patient relationship was an independent predictor of medication adherence (95% confidence interval [CI]: 0.29 to 5.89), whereas both illness perceptions (95% CI: −0.32 to −0.04) and the physician-patient relationship (95% CI: 1.05 to 9.48) were independent predictors of adherence to lifestyle modification guidance. Qualitative themes, reflecting the patient’s experience of the concepts explored in this study, explained the quantitative results. Mixing methods revealed high consistency between quantitative and qualitative findings. Limitations: Limitations are the inability to infer causal associations among variables and indirect measurement of medication adherence. Conclusion: Shared decision-making on antihypertensive medications promotes medication adherence. Specifically, the illness perception, perceived illness controllability, and non-judgemental patients’ acceptance within a satisfying physician-patient relationship empower patients to adhere to lifestyle modification guidance.

Did the UK’s COVID-19 restrictions during 2020 have a differential impact on the well-being of the LGBQ+ population: a mixed methods study

ObjectiveThe social distancing measures governments implemented in response to the COVID-19 pandemic have had substantial impacts. For some communities, these impacts will be disproportionate, with those communities experiencing inequalities, marginalisation...

The impact of atypical intrahospital transfers on patient outcomes: a mixed methods study

The architectural design of hospitals worldwide is centred around individual departments, which require the movement of patients between wards. However, patients do not always take the simplest route from admission to discharge, but can experience convoluted movement patterns, particularly when bed availability is low. Few studies have explored the impact of these rarer, atypical trajectories. Using a mixed-method explanatory sequential study design, we firstly used three continuous years of electronic health record data prior to the Covid-19 pandemic, from 55,152 patients admitted to a London hospital network to define the ward specialities by patient type using the Herfindahl–Hirschman index. We explored the impact of ‘regular transfers’ between pairs of wards with shared specialities, ‘atypical transfers’ between pairs of wards with no shared specialities and ‘site transfers’ between pairs of wards in different hospital site locations, on length of stay, 30-day readmission and mortality. Secondly, to understand the possible reasons behind atypical transfers we conducted three focus groups and three in-depth interviews with site nurse practitioners and bed managers within the same hospital network. We found that at least one atypical transfer was experienced by 12.9% of patients. Each atypical transfer is associated with a larger increase in length of stay, 2.84 days (95% CI 2.56–3.12), compared to regular transfers, 1.92 days (95% CI 1.82–2.03). No association was found between odds of mortality, or 30-day readmission and atypical transfers after adjusting for confounders. Atypical transfers appear to be driven by complex patient conditions, a lack of hospital capacity, the need to reach specific services and facilities, and more exceptionally, rare events such as major incidents. Our work provides an important first step in identifying unusual patient movement and its impacts on key patient outcomes using a system-wide, data-driven approach. The broader impact of moving patients between hospital wards, and possible downstream effects should be considered in hospital policy and service planning.

The “How” and “Why” Behind Clinical Site Visits: A Qualitative Study Exploring Director of Clinical Education Perspectives

Introduction. Several studies have investigated stakeholder perspectives regarding clinical site visits (SVs). An SV is one of the many ways of building strong relationships through collaborative communication. This study explored perceptions of directors of clinical education (DCEs) about why SVs are important, why they prefer certain methods of communication over others, and how they prioritize their decision-making process regarding structure and communication methods used. Literature Review. Barriers to conducting SVs exist, including scheduling challenges, time, and cost. Some studies suggest preferences for using in-person communication. Subjects. Fifteen DCEs from across the United States. Methods. Subjects participated in one-on-one semi-structured interviews. Transcripts were analyzed using a grounded theory approach and thematic analysis. Results. Six themes emerged from the data: (1) communication is vital, (2) SVs are fact-finding missions that serve multiple purposes, (3) flexibility is essential, (4) showing up in person has a strong impact, (5) DCEs strategically schedule in-person SVs, and (6) faculty assistance can be valuable. Some of the purposes of an SV include learning about the clinic's expectations, gathering data to ensure that the student is having a good experience, keeping current with curricular trends and contemporary practice, and building and nurturing relationships. Faculty may be able to assist in conducting SVs when properly trained. In-person SVs show a powerful message of support to students and clinicians. Discussion and conclusion. Similar to other stakeholders, DCEs value SVs for building, maintaining, and strengthening clinical and academic relationships. Site visits also bridge curricular gaps, support stakeholders, and help DCEs do their job. Directors of clinical education are strategic when considering SV structure, communication methods, and prioritizing student and clinician needs. Results were used in conjunction with prior findings of our mixed-methods explanatory sequential study to create recommendations, which will empower DCEs to advocate for resources to continue conducting SVs, particularly in-person SVs, especially under certain circumstances. Future research should explore clinician perspectives, specifically related to preferred communication methods, structure of the SV, and meeting with faculty other than the DCE.

Defining the capabilities and competencies of high-performing family physicians: a mixed methods study

IntroductionHigh-performing primary care is recognised as the foundation of an effective and efficient healthcare system. Many medical graduates report they are not prepared for independent practice. To date, no research...

Hardiness as a Resilience Factor for Adaptation in Families of Children With 22q11.2 Deletion Syndrome: A Mixed Methods Study of Parents' Perspectives.

22q11.2 deletion syndrome is a rare multisystem genetic disorder with over 200 associated characteristics, occurring in various combinations and severity. Extensive biomedical research has been undertaken on 22q11.2 deletion syndrome, however, there is a dearth of research on families' experiences of managing a family member with this condition. The complex and at times serious phenotypical presentation of the syndrome can make the management of the condition difficult for families. The aim of this mixed method explanatory sequential study was to investigate family hardiness as a resilience factor for adaptation in families of children with 22q11.2 deletion syndrome from parents' perspectives. We found that adaptation scores increased by 0.57 points (95% CI: 0.19-0.94) for every one-point increase in family hardiness score. Qualitative results indicated that acceptance of the child's diagnosis and support positively influenced hardiness whereas fears about the future and their experiences of loss negatively influenced hardiness.

Motivation to Become a Vocational Teacher As a Second Career: A Mixed Method Study

AbstractWithin the school-based vocational education and training system, so-called hybrid teachers, i.e. who both work in a vocational school and a business, can add value to the quality of VET as well as can solve ageing and the threat of shortages among VET teachers. In this research, the motivation of becoming a VET teacher as a second career and its perception by participants were examined using a mixed-method explanatory sequential study design. In the first phase, 114 VET teachers from 33 VET institutions in Lithuania were surveyed using the Factors Influencing Teaching (FIT) Choice scale. In the second phase, five vocational teachers were interviewed. The qualitative results supported and complemented the results of quantitative research by emphasizing the importance of intrinsic motivation to teach and explained in-depth the components of antecedent socialisation and perceptions of teaching. The results were discussed considering similar studies on second-career teachers conducted in other countries.

How do general hospitals respond to people diagnosed with a personality disorder who are distressed: A qualitative study of clinicians in mental health liaison.

WHAT IS KNOWN ON THE SUBJECT?: People diagnosed with a personality disorder might be more likely to have physical health problems and be admitted to the hospital. Treatment in hospitals might be complicated by mental health crises or self-injury, and barriers to NHS care may increase the risk of developing further illness with serious consequences. Literature on "personality disorder" and the general hospital has to date primarily focused on emergency departments. Research on how general hospital inpatient wards respond to people diagnosed with a "personality disorder" has been long overdue. Thirteen clinicians working in mental health liaison in the general hospital were interviewed as part of a sequence of research studies. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE: This study identified unjust and avoidable differences in the care and treatment received by people diagnosed with a "personality disorder" in general hospitals. People with a "personality disorder" diagnosis were discriminated against and over- and under-medicated. Mental health liaison clinicians reported limited understanding and skills among general hospital clinicians. People working in general hospitals were fearful of the "personality disorder" diagnosis. Poor care was accepted because general hospital clinicians did not consider themselves to be "mental health trained." WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Clinicians working in mental health liaison need credible knowledge of mental and physical health and medicines. Capability, influence, and high-level interpersonal skills are needed to successfully work across mental health services and the general hospital. More advanced and consultant-level nursing roles in more mental health liaison teams are needed to strengthen this specialist workforce. ABSTRACT: Introduction Literature on "personality disorder" and the general hospital has to date primarily focused on emergency departments. Research on how general hospital inpatient wards respond to people diagnosed with a "personality disorder" has been long overdue. Aim Qualitative telephone interviews were undertaken to explore the views and perspectives of clinicians working in mental health liaison in this final strand of a mixed methods explanatory sequential study. Method Participants were recruited via social media and professional networks by snowball sampling. Data were analysed using a framework approach. Results Four themes were identified: knowledge, understanding, skills, and discriminatory practice; alliances, diplomacy, care, and treatment of people diagnosed with a "personality disorder"; achieving parity of esteem in a disparate healthcare system; and organizational stress, mismatched expectations, and service led decision-making. Discussion There were unjust and avoidable differences in the care and treatment received by people diagnosed with a "personality disorder" in the general hospital. People were discriminated against and routinely over- and under-medicated. Implications for practice Clinicians working in mental health liaison need capacity for partnership working, clinical capability spanning mental and physical health, credibility and influence and high-level interpersonal skills to address the entrenched discrimination of people diagnosed with a "personality disorder."

Involvement of high school teachers in Health Promoting School program in selected township, Yangon Region, Myanmar: A cross-sectional mixed methods study.

BackgroundSchools provide a big opportunity for promoting the student’s health, life skill, and behavior. Teachers play a fundamental role in the promotion and successful implementation of school health services. This study aimed to assess the level of involvement in the Health Promoting School program and its associated factors and to explore the benefits and barriers to involvement among high school teachers in Myanmar.MethodsA mixed methods explanatory sequential study was conducted among 194 high school teachers in Thanlyin Township, Yangon Region, Myanmar, from June to August 2020. Quantitative data were collected with the pretested structural questionnaire and analyzed by Chi-square tests and Fisher’s exact tests. A qualitative strand was added by conducting in-depth interviews (n = 15, five teachers from each level of involvement: poor, medium, and good), analyzed by thematic content analysis.ResultsOf the 194 teachers, 23.7% had a good level of involvement in the Health Promoting School program. The factor associated with involvement in Health Promoting School program were age (p value < 0.001), duration of services (p value = 0.001), and a number of accomplished training-related school health (p value = 0.008). Qualitative data revealed that improvement of the health knowledge and awareness on health problems, the progress of healthy behaviors, development of physical and mental health, prevention of the disease spread, achievement of healthy and productive learning environment, and development of academic achievement were major benefits of teachers’ involvement. Moreover, the main barriers to involvement were insufficient materials and human resources, time constraints, incompetence of the teachers, poor cooperation of school health partnerships, and insufficient awareness of parents.ConclusionsThe proportion of good involvement in the Health Promoting School program among high school teachers was low in this study area. Providing sufficient human resources and material, conducting the on-the-job and refresher training, enhancing parent-teacher cooperation, and strengthening the community partnerships were crucial to improve the level of involvement and reduced the barriers for the achievement of the Health Promoting School program.

Factors that Sustained the Integration of Behavioral Health into Nurse-Led Primary Care.

Lack of access to primary and behavioral healthcare is prevalent in communities experiencing systematically greater obstacles to healthcare. This study describes the implementation of the Coordinated Care Model in a nurse-led primary care clinic and identifies the essential factors for sustained integration. A mixed-methods explanatory sequential study design was used to collect and analyze quantitative and qualitative data. Participants reported an overall statistically significant mean increase (M = 2.47, SD ± 2.01, p < 0.001) in the level of integration pre-and post-integration. Qualitative results indicated that the optimization and accentuation of team strengths, the Lundeen model of holistic care, and addressing physical and psychological barriers lead to sustained level of integration. Integrated practices are essential in assessing and supporting the holistic needs of individuals, families, and communities. Future studies should examine facilitators or impediments to integrated practice in other healthcare settings, long-term health outcomes of clients in integrated care, and the cost-effectiveness of integration.

Examination of Chinese immigrant parents' beliefs about children's social development through play: A mixed methods explanatory sequential study.

Currently, despite the rapid growth of the population of Chinese immigrant families and children in the United States, preschool-aged Chinese-heritage children are an underrepresented group in research. The overarching purpose of this project was to provide a deeper understanding of Head Start Chinese immigrant parents' beliefs about children's social-emotional development, the value of play during the preschool period, and the potential role of cultural orientation. The study followed the steps of a mixed methods explanatory sequential design. First, using quantitative data collected from 213 primary caregivers, the study employed a person-centered lens to explore profiles of parents' cultural orientations and beliefs about play and academics in preschool to better understand the association of these profiles to children's social competencies. Next, 34 primary caregivers from the quantitative study participated in in-depth, focus group discussions to further explore parents' perceptions of children's social behaviors, cultural adjustment experiences, and their perceptions about U.S. preschools. Four reliable profiles were resolved quantitatively and showed within-group variations in patterns of Chinese immigrant parents' beliefs and cultural orientations that related differentially to children's social-emotional competencies as evidenced within peer play at home. Qualitative findings corroborated and elaborated the quantitative findings. These results underscored the importance of engaging with Chinese immigrant parents to inform research and program practices. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Exploring Systemic Influences on Data-Informed Learning: Document Review of Policies, Procedures, and Legislation from Canada and the United States.

Despite the support for and benefits of data-driven learning, physician engagement is variable. This study explores systemic influences of physician use of data for performance improvement in continuing professional development (CPD) by analyzing and interpreting data sources from organizational and institutional documents. The document analysis is the third phase of a mixed-methods explanatory sequential study examining cultural factors that influence data-informed learning. A gray literature search was conducted for organizations both in Canada and the United States. The analysis contains nonparticipant observations from professional learning bodies and medical specialty organizations with established roles within the CPD community known to lead and influence change in CPD. Sixty-two documents were collected from 20 Canadian and American organizations. The content analysis identified the following: (1) a need to advocate for data-informed self-assessment and team-based learning strategies; (2) privacy and confidentiality concerns intersect at the point of patient data collection and physician-generated outcomes and need to be acknowledged; (3) a nuanced data strategy approach for each medical specialty is needed. This analysis broadens our understanding of system-level factors that influence the extent to which health information custodians and physicians are motivated to engage with data for learning.

A mixed-methods study of novice teachers’ technology integration: Do they leverage their TPACK knowledge once entering the profession?

Research indicates educators benefit from developing Technological Pedagogical Content Knowledge (TPACK), a combination of constructs that inform the design of pedagogically-sound technology-integrated instruction. Applying a mixed-methods explanatory sequential study design, we examined if and how novice K-12 teachers, who developed TPACK during the same teacher education program, transferred that knowledge to their full-time teaching upon graduation. A total of 50 participants completed a survey that explored their perspectives of technology integration. Interviews were conducted with 20 participants to further examine the survey results. Three significant findings were identified: (1) participants perceived technology integration as important to their teaching, (2) a disconnect existed between teachers’ perceived importance of technology-integrated activities and actual integration, and (3) persistent barriers continued to challenge teachers’ integration of technology.

External wine education and certification for restaurant service staff: a mixed-methods evaluation of training effectiveness

PurposeThe purpose of this mixed-methods explanatory sequential study was to assess the effects of an external wine education and certification program on trainee reactions, learning, transfer and financial results.Design/methodology/approachThe quantitative phase was a mixed experimental design in which the training intervention was between-subjects and time was within-subjects. The sample comprises 91 employees (NTraining = 43; NControl = 48) from 12 units of a fine dining restaurant group. The qualitative phase, comprised of semi-structured interviews with training group participants (N = 12), was implemented after the experiment.FindingsTraining group participants reported high scores for attitude toward training content, instructional satisfaction and transfer motivation. Financial metrics, tracked up to 60 days post-training, demonstrated the wine education program was effective in increasing wine knowledge but not wine sales. Four themes emerged from the qualitative data: sense of accomplishment, enhanced guest interaction, tips and gratuities and defeat. Integrated findings revealed increased wine knowledge led to personal financial impact (increased tips) rather than organizational impact.Originality/valueThis research builds on existing training literature and human capital theory by examining external training programs. Further, the use of a mixed-methods design and integration of the quantitative and qualitative findings offers a previously unidentified explanation for why wine training, although effective in facilitating positive reactions and learning, fails to result in transfer behaviors which generate increased wine sales.

Exploring the Impact of an Open Access Mindfulness Course with Online Graduate Students: A Mixed Methods Explanatory Sequential Study

As enrollment in online graduate education increases, retention continues to be problematic for many colleges and universities across the United States. Non-traditional students, who represent the majority of online graduate student enrollment, have unique issues related to persistence considering they often must juggle the demands of graduate school with work and families. The competing demands can lead to increased levels of perceived stress, which can impact academic performance due to increased mind wandering and decreased attention. Mindfulness is a practice that has been shown in the literature to decrease levels of perceived stress and mind wandering, therefore, the integration of mindfulness practice could have a positive effect on student persistence in online graduate education. Therefore, an online open access mindfulness course was created at one large urban university. The purpose of this explanatory sequential study was to explore the impact of teaching mindfulness to online graduate students. Self-report levels of perceived stress and mind wandering were significantly lower after students completed Module One of an open access mindfulness course. Self-reported perceived persistence levels were found to be significantly higher after Module One with students in the first or second quarter of their program, students with little or no mindfulness experience, and students who meditated four or more times a week. Furthermore, students interviewed felt that the course provided excellent foundational information about mindfulness that could be immediately applied, and therefore should be a requirement for all incoming students.

Knowledge and beliefs about the use/abuse of oral contraceptive pills among males: A mixed-method explanatory sequential study in community pharmacy settings

BackgroundOral contraceptive pills (OCPs) are considered one of the most important birth control methods globally. However, these pills were designed for female administration rather than males. This study was designed to investigate patterns of OCPs use and abuse among Jordanian males, according to the community pharmacists’ observations.MethodA mixed-method explanatory sequential study was conducted using an online self-administered survey, followed by semi-structured in-depth interviews for registered pharmacists, assistant pharmacists and pharmacy interns. The interviews were utilized using a conceptual framework. Inductive thematic analysis and descriptive/regression analyses were completed using Nvivo and SPSS, respectively.ResultsA total of 158 questionnaire responses and 22 interviews were included in our analysis. Around half (48.4%) of the questionnaire responses confirmed that males could use OCPs for hair growth enhancement, muscle gain and acne treatment 12.7%, 31.7% and 4.4%, respectively. Through the interviews, the participating pharmacists highlighted that males use OCPs mostly for bodybuilding purposes, according to recommendations by their coaches at the gym. The most abused OCPs containing estrogen (Ethinyl estradiol) and progestins (Drospirenone or Levonorgestrel).ConclusionThis study provided insight into unexpected uses of OCPs by males in Jordan. Community pharmacists have a crucial role in the management of OCPs use and abuse. However, restricted regulations and monitoring must be released and implemented on the community to limit such practices.

Perceived Benefits of a Standardized Patient Simulation in Pre-Placement Dietetic Students

The purpose of this study was to evaluate the effect of a simulation-based learning (SBL) experience on perceived confidence in monitoring and evaluation, as part of the delivery of nutrition care of pre-placement dietetic students, and to describe their perceived value of the learning experience post-placement. A mixed method explanatory sequential study design was used. A confidence appraisal scale was developed and completed by students before (n = 37) and after (n = 33) a low fidelity simulation using a volunteer patient in an acute care setting. Two semi-structured focus group discussions with post-placement students (n = 17) were thematically analysed, grounded in phenomenology. Overall perceived confidence in monitoring and evaluating, as part of nutrition care, improved after the simulation [pre-SBL: 74 (62–83) vs. post-SBL: 89 (81–98.5), p = 0.00]. Two factors emerged to modulate confidence, namely (i) structure and (ii) authentic learning. Structure in turn was modulated by two key factors; safety and process. A low fidelity simulation using a standardised patient can improve students’ perceived confidence in monitoring and evaluation, and a well-structured authentic learning experience was valued and positively perceived by most dietetic students.

Determinants of delayed diagnosis and treatment of tuberculosis in Cambodia: a mixed-methods study

BackgroundCambodia is among the 30 countries in the world with the highest burden of tuberculosis (TB), and it is estimated that 40% of people with TB remain undiagnosed. In this study, we aimed to investigate the determinants of delayed diagnosis and treatment of TB in Cambodia.MethodsThis mixed-method explanatory sequential study was conducted between February and September 2019 in 12 operational districts in Cambodia. It comprised of a retrospective cohort study of 721 people with TB, followed by a series of in-depth interviews. We assessed factors associated with time to TB diagnosis and treatment initiation using Cox proportional hazards model. Subsequently, we conducted in-depth interviews with 31 people with TB purposively selected based on the time taken to reach TB diagnosis, sex, and residence. Transcripts were coded, and thematic analyses were performed.ResultsThe median time from the onset of symptoms to TB diagnosis was 49 days (Interquartile range [IQR]: 21–112). We found that longer time to diagnosis was significantly associated with living in rural area (Adjusted hazards ratio [aHR] = 1.25; 95% confidence interval [CI]: 1.06–1.48); TB symptoms—cough (aHR: 1.52; 95% CI: 1.18–1.94), hemoptysis (aHR 1.32; 95% CI: 1.07–1.63), and night sweats (aHR: 1.24; 95% CI: 1.05–1.46); seeking private health care/self-medication (aHR: 1.23; 95% CI: 1.04–1.45); and higher self-stigma (aHR: 1.02; 95% CI: 1.01–1.03). Participants who received education level above the primary level were inversely associated with longer time to diagnosis (aHR: 0.78; 95% CI: 0.62–0.97). The median time from TB diagnosis to the initiation of treatment was two days (IQR: 1–3). The use of smear microscopy for TB diagnosis (aHR: 1.50; 95% CI: 1.16–1.95) was associated with longer time to treatment initiation. Seeking private health care and self-medication before TB diagnosis, lack of perceived risk, threat, susceptibility, and stigma derived qualitatively further explained the quantitative findings.ConclusionsTB diagnostic delay was substantial. Increasing public awareness about TB and consciousness regarding stigma, engaging the private healthcare providers, and tailoring approaches targeting the rural areas could further improve early detection of TB and narrowing the gap of missing cases in Cambodia.

Sustainability of the streamlined ART (START-ART) implementation intervention strategy among ART-eligible adult patients in HIV clinics in public health centers in Uganda: a mixed methods study

BackgroundDespite increasing access to antiretroviral therapy (ART), the proportion of eligible patients initiated on treatment remains suboptimal. Only 64.6% of the people living with HIV (PLHIV) globally were initiated on ART by June 2019. The streamlined ART (START-ART) implementation study was based on the PRECEDE model, which suggests that “predisposing, enabling, and reinforcing” factors are needed to create behavior change. START-ART increased ART initiation within 2 weeks of eligibility by 42%. However, the gains from some implementation interventions erode over time. We evaluated facilitators and barriers to sustainability of this streamlined ART initiation in the year following the implementation period.MethodsWe designed a mixed-methods explanatory sequential study to examine the sustainability of START-ART implementation. Quantitative component consisted of cross-sectional patient chart reviews of routinely collected data; qualitative component consisted of key informant interviews of health workers in START-ART facilities 2 years after conclusion of the implementation period. We analyzed data from 15 public health centers of Mbarara district, where the START-ART implementation was carried out. We included PLHIV aged > 18 years who initiated ART from June 2013 to July 2016. The START-ART implementation took place from June 2013 to June 2015 while the sustainability period was from August 2015 to July 2016.ResultsA total of 863 ART-eligible patients were sampled. The median CD4 count was 348 cells/ml (IQR 215–450). During the intervention, 338 (77.4%) eligible patients initiated on ART within 2 weeks compared with 375 (88.2%) during the sustainability period (risk difference 10.8%; 95% CI 5.9–15.8%). In 14 of the 15 health centers, the intervention was sustained. During key informant interviews, rapid ART initiation sustainability was attributed to counseling skills that were obtained during intervention and availability of point-of-care (POC) CD4 PIMA machine. Failure to sustain the intervention was attributed to three specific barriers: lack of training after the intervention, transfer of trained staff to other health facilities, and shortage of supplies like cartridges for POC CD4 PIMA machine.ConclusionRapid ART initiation was sustained in most health centers. Skills acquired during the intervention and functional POC CD4 machine facilitated while staff transfers and irregular laboratory supplies were barriers to sustainability of rapid ART initiation.

Visto, Pero No Escuchado: A Qualitative Arm of a Mixed-Methods Study of Puerto Rican Children With Asthma.

Communication among health care providers, caregivers, and children with asthma is challenging and sometimes may exclude the child. This may result in delay in recognizing and responding appropriately to asthma symptoms. The purpose was to conduct focus groups among Puerto Rican children with asthma on communication with their health care provider about their asthma symptoms. The qualitative arm (focus groups) of a mixed-method explanatory sequential study that was used to view communication with their health care provider through the lens of a group of Puerto Rican children. The sample included Puerto Rican children ages 8 to 12 years with asthma (N = 23). The goal was to develop a child illness representation questionnaire. The perspective of children with asthma provided enriched information to influence the development of instrument subscale on communication. The children were often not heard during a clinical visit. Most of the children express fear of their health care provider. Although this was a small sample, there were indications that children would like to opportunity to tell the story about their experience with having asthma. Further research will lead to the next step toward developing and computing a reliable measure that includes the child in a discussion during a clinical visit.