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Harvard T.H. Chan School of Public Health Case-Based Teaching & Learning Initiative

Teaching cases & active learning resources for public health education, case library.

The Harvard Chan Case Library is a collection of teaching cases with a public health focus, written by Harvard Chan faculty, case writers, and students, or in collaboration with other institutions and initiatives.

Use the filters at right to search the case library by subject, geography, health condition, and representation of diversity and identity to find cases to fit your teaching needs. Or browse the case collections below for our newest cases, cases available for free download, or cases with a focus on diversity. 

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Many of our cases are available for sale through Harvard Business Publishing in the  Harvard T.H. Chan case collection . Others are free to download through this website .

Cases in this collection may be used free of charge by Harvard Chan course instructors in their teaching. Contact  Allison Bodznick , Harvard Chan Case Library administrator, for access.

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Teaching notes are available as supporting material to many of the cases in the Harvard Chan Case Library. Teaching notes provide an overview of the case and suggested discussion questions, as well as a roadmap for using the case in the classroom.

Access to teaching notes is limited to course instructors only.

• Teaching notes for cases available through  Harvard Business Publishing may be downloaded after registering for an Educator account .
• To request teaching notes for cases that are available for free through this website, look for the "Teaching note  available for faculty/instructors " link accompanying the abstract for the case you are interested in; you'll be asked to complete a brief survey verifying your affiliation as an instructor.

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Faculty and instructors with university affiliations can register for Educator access on the Harvard Business Publishing website,  where many of our cases are available . An Educator account provides access to teaching notes, full-text review copies of cases, articles, simulations, course planning tools, and discounted pricing for your students.

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Atkinson, M.K. , 2023. Organizational Resilience and Change at UMass Memorial , Harvard Business Publishing: Harvard T.H. Chan School of Public Health. Available from Harvard Business Publishing Abstract The UMass Memorial Health Care (UMMHC or UMass) case is an examination of the impact of crisis or high uncertainty events on organizations. As a global pandemic unfolds, the case examines the ways in which UMMHC manages crisis and poses questions around organizational change and opportunity for growth after such major events. The case begins with a background of UMMHC, including problems the organization was up against before the pandemic, then transitions to the impact of crisis on UMMHC operations and its subsequent response, and concludes with challenges that the organization must grapple with in the months and years ahead. A crisis event can occur at any time for any organization. Organizational leaders must learn to manage stakeholders both inside and outside the organization throughout the duration of crisis and beyond. Additionally, organizational decision-makers must learn how to deal with existing weaknesses and problems the organization had before crisis took center stage, balancing those challenges with the need to respond to an emergency all the while not neglecting major existing problem points. This case is well-suited for courses on strategy determination and implementation, organizational behavior, and leadership.

The case describes the challenges facing Shlomit Schaal, MD, PhD, the newly appointed Chair of UMass Memorial Health Care’s Department of Ophthalmology. Dr. Schaal had come to UMass in Worcester, Massachusetts, in the summer of 2016 from the University of Louisville (KY) where she had a thriving clinical practice and active research lab, and was Director of the Retina Service. Before applying for the Chair position at UMass she had some initial concerns about the position but became fascinated by the opportunities it offered to grow a service that had historically been among the smallest and weakest programs in the UMass system and had experienced a rapid turnover in Chairs over the past few years. She also was excited to become one of a very small number of female Chairs of ophthalmology programs in the country. 

Dr. Schaal began her new position with ambitious plans and her usual high level of energy, but immediately ran into resistance from the faculty and staff of the department.  The case explores the steps she took, including implementing a LEAN approach in the department, and the leadership approaches she used to overcome that resistance and build support for the changes needed to grow and improve ophthalmology services at the medical center. 

This case describes efforts to promote racial equity in healthcare financing from the perspective of one public health organization, Community Care Cooperative (C3). C3 is a Medicaid Accountable Care Organization–i.e., an organization set up to manage payment from Medicaid, a public health insurance option for low-income people. The case describes C3’s approach to addressing racial equity from two vantage points: first, its programmatic efforts to channel financing into community health centers that serve large proportions of Black, Indigenous, People of Color (BIPOC), and second, its efforts to address racial equity within its own internal operations (e.g., through altering hiring and promotion processes). The case can be used to help students understand structural issues pertaining to race in healthcare delivery and financing, to introduce students to the basics of payment systems in healthcare, and/or to highlight how organizations can work internally to address racial equity.

Kerrissey, M.J. & Kuznetsova, M. , 2022. Killing the Pager at ZSFG , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract This case is about organizational change and technology. It follows the efforts of one physician as they try to move their department past using the pager, a device that persisted in American medicine despite having long been outdated by superior communication technology. The case reveals the complex organizational factors that have made this persistence possible, such as differing interdepartmental priorities, the perceived benefits of simple technology, and the potential drawbacks of applying typical continuous improvement approaches to technology change. Ultimately the physician in the case is not able to rid their department of the pager, despite pursuing a thorough continuous improvement effort and piloting a viable alternative; the case ends with the physician having an opportunity to try again and asks students to assess whether doing so is wise. The case can be used in class to help students apply the general concepts of organizational change to the particular context of technology, discuss the forces of stasis and change in medicine, and to familiarize students with the uses and limits of continuous improvement methods. 

Yatsko, P. & Koh, H. , 2021. Dr. Joan Reede and the Embedding of Diversity, Equity, and Inclusion at Harvard Medical School , Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract For more than 30 years, Dr. Joan Reede worked to increase the diversity of voices and viewpoints heard at Harvard Medical School (HMS) and at its affiliate teaching hospitals and institutes. Reede, HMS’s inaugural dean for Diversity and Community Partnership, as well as a professor and physician, conceived and launched more than 20 programs to improve the recruitment, retention, and promotion of individuals from racial and ethnic groups historically underrepresented in medicine (UiMs). These efforts have substantially diversified physician faculty at HMS and built pipelines for UiM talent into academic medicine and biosciences. Reede helped embed the promotion of diversity, equity, and inclusion (DEI) not only into Harvard Medical School’s mission and community values, but also into the DEI agenda in academic medicine nationally. To do so, she found allies and formed enduring coalitions based on shared ownership. She bootstrapped and hustled for resources when few readily existed. And she persuaded skeptics by building programs using data-driven approaches. She also overcame discriminatory behaviors and other obstacles synonymous with being Black and female in American society. Strong core values and sense of purpose were keys to her resilience, as well as to her leadership in the ongoing effort to give historically marginalized groups greater voice in medicine and science.

Cases Available for Free Download

Cash, R., et al. , 2009. Casebook on ethical issues in international health research , World Health Organization. Publisher's Version Abstract This casebook published by the World Health Organization contains 64 case studies, each of which raises an important and difficult ethical issue connected with planning, reviewing, or conducting health-related research. Available for download free of charge from the World Health Organization in English, Arabic, Russian, and Spanish.

In 2011 in response to two high profile cases of maternal death during labor and delivery, Ugandan citizens mobilized to prevent maternal mortality by improving the delivery of healthcare services in public hospitals. The Coalition to Stop Maternal Mortality ignited a social movement by utilizing strategic advocacy to hold the Government of Uganda accountable to its constitutional provisions on health service delivery. This case examines the Coalition to Stop Maternal Mortality and its landmark legal initiative, Constitutional Petition No. 16 of 2011, that focused the nation’s attention on the state of health services in Uganda and initiated a nationwide conversation about the role of government in delivering the right to health for all Ugandans.  What tactics and strategies can effectively mobilize power to bring about legal and policy change?  Would these be enough to achieve the change that the Coalition sought?

Guyer, A.L., Wirtz, V.J. & Reich, M.R. , 2019. Monitoring and Evaluation for the Novartis Access Initiative , Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract This case is located within the multinational pharmaceutical company Novartis, as key managers decide what kind of monitoring and evaluation to implement for one of its social business programs,  Novartis Access . This new program will expand the company’s reach into traditionally underserved markets in low- and middle-income countries using a basket of 15 medicines for non-communicable diseases offering them at public and faith-based facilities at a lower price than sold in the private market.  Novartis Access  is being launched in late 2015 in Kenya, with a long-term goal of operating in 30 countries. The case focuses on Michael Fürst, Senior Manager for Corporate Responsibility Strategy and Innovation, who must prepare a plan for monitoring and evaluation for Novartis Access to present to Harald Nusser, Head of Novartis Social Business. In order to prepare for his first meeting with Harald Nusser, Michael Fürst needs to identify the value and risks of monitoring and evaluating (and their differences) and make a proposal about what kind of monitoring and evaluation to adopt (if any), and how to overcome internal and external challenges.

Teaching note available for faculty/instructors .

In February 2015, technical staff reviewed the results from a jointly conducted study on malaria control. This study had major implications for malaria in Zambia—and elsewhere. The preliminary analysis strongly suggested that the study’s Mass Drug Administration (MDA) strategy was reducing the incidence of malaria disease. In addition, MDA seemed to be driving down the infection reservoir among asymptomatic people in the study area of the Southern Province of Zambia. Further analysis with mathematical models indicated that if the intervention was sustained so current trends continued, then the MDA strategy would make it possible to eliminate malaria in the Southern Province. 

If malaria could be eliminated in one region of Zambia, that would provide new evidence and motivation to work towards elimination throughout the country, an ambitious goal. But it would not be easy to move from conducting one technical study in a single region to creating a national strategy for malaria elimination. The scientists realized that their new data and analyses—of malaria infections, mosquito populations, and community health worker activities—were not enough. A national malaria elimination effort would require mobilizing many partners, national and local leaders, and community members, and convincing them to get on board with this new approach. 

Focus on Diversity, Equity, and Inclusion

This module will present two unfolding case studies based on real-world, actual events. The cases will require participants to review videos embedded into three modules and a summary module: Introduction to Concepts of Social Determinant of Health and Seeking Racial Equity  Case Study on Health and Healthcare Context - Greensboro Health Disparities Collaborative (GHDC)​    Case Study on Social and Community Context - Renaissance Community Cooperative (RCC) Summary (Optional)

The learning objectives for the modules are related to achieving the Healthy People 2020 Social Determinants of Health Objectives – specifically the (1) Health and Healthcare Context, and (2) Social and Community Context.   

Al Kasir, A., Coles, E. & Siegrist, R. , 2019. Anchoring Health beyond Clinical Care: UMass Memorial Health Care’s Anchor Mission Project , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract As the Chief Administrative Officer of UMass Memorial Health Care (UMMHC) and president of UMass Memorial (UMM) Community Hospitals, Douglas Brown had just received unanimous and enthusiastic approval to pursue his "Anchor Mission" project at UMMHC in Worcester, Massachusetts. He was extremely excited by the board's support, but also quite apprehensive about how to make the Anchor Mission a reality. Doug had spearheaded the Anchor Mission from its earliest exploratory efforts. The goal of the health system's Anchor Mission-an idea developed by the Democracy Collaborative, an economic think tank-was to address the social determinants of health in its community beyond the traditional approach of providing excellent clinical care. He had argued that UMMHC had an obligation as the largest employer and economic force in Central Massachusetts to consider the broader development of the community and to address non-clinical factors, like homelessness and social inequality that made people unhealthy. To achieve this goal, UMMHC's Anchor Mission would undertake three types of interventions: local hiring, local sourcing/purchasing, and place-based community investment projects. While the board's enthusiasm was palpable and inspiring, Doug knew that sustaining it would require concrete accomplishments and a positive return on any investments the health system made in the project. The approval was just the first step. Innovation and new ways of thinking would be necessary. The bureaucracy behind a multi-billion-dollar healthcare organization would need to change. Even the doctors and nurses would need to change! He knew that the project had enormous potential but would become even more daunting from here.

Weinberger, E. , 2017. Coloring the Narrative: How to Use Storytelling to Create Social Change in Skin Tone Ideals , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract Many millions of people around the world experience the pervasive, and often painful, societal messages of colorism, where lighter skin tones are asserted to be more attractive and to reflect greater affluence, power, education, and social status. Even in places where the destructive effects of colorism are fairly well understood, far less is known about the problem of skin-lightening (really, it’s “skin bleaching”) creams and lotions, and the health risks that consumers assume with these products. In this teaching case, the protagonists are two women who have recently immigrated to the United States from Nigeria and Thailand, both with a life-time of experience with these products like many of the women of their home countries. As the story unfolds, they struggle along with the rest of the characters to copy with the push and pull of community norms vs. commercial influences and the challenge of promoting community health in the face of many societal and corporate obstacles. How can the deeply ingrained messages of colorism be effectively confronted and transformed to advance social change without alienating the community members we may most want to reach? Teaching note and supplemental slides available for faculty/instructors .

This teaching case study examines psychological trauma in a community context and the relevance, both positive and negative, of social determinants of health. Healthy People 2020 views people residing in communities with large-scale psychological trauma as an emerging issue in mental health and mental health disorders (Healthy People, 2016). The case study, which focuses on Newark, New Jersey, addresses three of the five key determinants of health: social and community context, health and health care, and neighborhood and built environment. The three key determinants are addressed using psychological trauma as an exemplar in the context of trauma-informed systems. The social and community context is addressed using concepts of social cohesion, civic participation, and discrimination. Access to health and health care are addressed with discussion of access to mental health and primary care services, health literacy, and the medical home model. Neighborhood and built environment are viewed through the lens of available government and NGO programs and resources to improve the physical environment with a focus on quality of housing, crime and violence, and environmental conditions. Upstream interventions designed to improve mental health and well-being that support trauma-informed systems are analyzed. The use of Newark as the case study setting allows a real-life exploration of each of these three key determinants of health.

This case study has four sections – introduction, case study, side bar, and vignettes. Learners should work through the case, access appropriate resources, and work in a team for successful completion.

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Browse our case library

Holman, S.R. & Balsari, S. , 2017. Stampede at the Kumbh Mela: Preventable Accident? , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This teaching case describes the fatal stampede in Allahabad, India during the 2013 Kumbh Mela festival, and the lessons it offers for thinking about global health risks and responses to unintentional accidents and injuries related to mass gatherings. The case is part of a teaching pack, “Accidents & Injuries: Lessons from a Stampede,” which also includes a companion instructor’s guide, discussion guide, role-play exercise, annotated bibliography, and glossary of terms. The case is suitable for undergraduate and graduate classes in the study of religion, humanitarian aid, public health, and emergency medicine with a focus on disaster management.

The Envision Healthcare (EVHC) case examines the operations of one of EVHC's divisions, EmCare, a national physician services outsourcing company. The case describes EmCare's controversial use of out-of-network billing for a significant share of its revenues. As the company faced increasingly negative scrutiny for these practices, the case highlights the different perspectives and vantage points- both good and bad- of this strategic decision, and delves into the question of ethical practices as it relates to out-of-network billing. Students will explore the legal, societal, and economic implications of EmCare's business model, grappling with questions of business ethics and responsibility to customers. As EVHC contemplates reducing the out-of-network billing practices of its divisions including EmCare, the company faces important questions around financial viability, which serve as an opportunity for students to develop recommendations and novel approaches to EVHC's strategic quandary.

Ethical challenges are common to healthcare organizations as they develop and implement strategy. Organizations must deal with questions of profitability and performance against the backdrop of making self-guided decisions around social responsibility and ethical practices. The case provides relevant context regarding emergency medicine, out-of-network billing, and payer-provider-hospital relationships. With this background, students are encouraged to consider the gamut of considerations, some of which are not so obvious, when weighing strategic decisions that bear in mind social and ethical implications.

2018. Western Public Health Casebooks: Cases from the Schulich Interfaculty Program in Public Health , Western University: Schulich School of Medicine & Dentistry. Access online Abstract A collection of cases written by MPH students of the Schulich Interfaculty Program in Public Health at Western University, Canada. These casebooks--from 2015, 2016, 2017, and 2018--may be copied and used free of charge without permission for any educational uses by an accredited educational institution.

Jessie Gaeta, the chief medical officer for Boston Health Care for the Homeless Program (BHCHP), learned on April 7, 2020 that the City of Boston needed BHCHP to design and staff in 48 hours one half of Boston Hope, a 1,000-bed field hospital for patients infected with COVID-19. The mysterious new coronavirus spreading around the world was now running rampant within BHCHP's highly vulnerable patient population: people experiencing homelessness in Boston. A nonprofit community health center, BHCHP for 35 years had been the primary care provider for Boston's homeless community. Over the preceding month, BHCHP's nine-person incident command team, spearheaded by Gaeta and CEO Barry Bock, had spent long hours reorganizing the program. (See Boston Health Care for the Homeless (A): Preparing for the COVID-19 Pandemic.) BHCHP leaders now confronted the most urgent challenge of their long medical careers. Without previous experience in large-scale disaster medicine, Gaeta and her colleagues had in short order to design and implement a disaster medicine model for COVID-19 that served the unique needs of people experiencing homelessness.

This case study recounts the decisive actions BHCHP leaders took to uncover unexpectedly widespread COVID-19 infection among Boston's homeless community in early April 2020. It details how they overcame their exhaustion to quickly design, staff, and operate the newly erected Boston Hope field hospital for the city's homeless COVID-19 patients. It then shows how they adjusted their disaster medicine model when faced with on-the-ground realities at Boston Hope regarding patients' psychological needs, limited English capabilities, substance use disorders, staff stress and burnout, and other issues.

Weinberger, E. , 2014. Some Skin in the Game: Negotiating the End of a Campus Health Menace , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract Fictitious Colburn University boasts many “amenities” for its students, including cafes, a gymnasium, and U.V. tanning salon Campus Tans. Meredith Tang, a law student originally from Australia, and Barbara Holly, a public health student, cannot believe that this insidious industry has infiltrated campus life and worse yet seems to be promoted by the school, or at least is allowed to advertise on campus. Soon these students turned activists begin a campaign to evict the salon; however, they quickly discover that evicting Campus Tans may not be as easy as they thought. As the story ends, the student activists sit down to a meeting with school officials and the owner of the salon to negotiate an agreement that protects the health of Colburn students while balancing the interests of diverse stakeholders. Teaching note available for faculty/instructors .

This multimedia module includes three clinical case videos demonstrating a variety of geriatric patient circumstances. Participants will view each case with attention to the medical care provided, as well as the impact of the social determinants of health (SDOH) in each scenario. The provider, in each case, models how to integrate the SDOH into the care plan to optimize the patient’s health and functionality.

Facilitators who utilize this module will develop panels from local community and state agencies to follow each case. The panels serve to deepen the learning experience through discussion and linking the participants to local experts. This strengthens the participant’s ability to apply lessons learned from this module in the clinical community contexts they serve.

The learning objectives for this module are directly related to Healthy People 2020 with the core SDOH categories including: economic stability; social and community context; health and healthcare; neighborhood and built environment; and environmental conditions. 

When Dr. Marwan started as director of Ramses Hospital in Cairo in 2008, charged by the Minister of Health with improving performance, he found the hospital had been neglected for decades. A Ministry of Health quality audit had recently given the hospital the worst score of the five hospitals designated as critical to the greater Cairo area. 

Dr. Marwan vowed that Ramses Hospital would come in first in the next round of quality audits. Without improving its quality scores, the hospital would be unable to pass the accreditation process required for hospital participation in a new universal social health insurance scheme. In addition—and just as critically—Dr. Marwan needed to develop a longer-term strategy for obtaining the considerable additional resources required to upgrade the long-neglected facility.

Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line (2020)

Chapter: chapter 6 - case studies: health promotion programs.

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

53 6.1 Introduction The case studies and analyses presented in this chapter introduce primary source employee demographic and wellness program participation data collected from five major metropolitan transit agencies: • The Indianapolis Public Transportation Corporation (IndyGo), in Indianapolis, Indiana; • The Regional Transit Service (RTS), in Rochester, New York; • The Transit Authority of River City (TARC), in Louisville, Kentucky; • The Des Moines Area Regional Transit Authority (DART), in Des Moines, Iowa; and • The Los Angeles Metropolitan Transit Agency (LA Metro), in Los Angeles, California. The analysis involved a review of descriptive literature publicly available from agencies or provided to the project team by the agencies, human resources records, insurance company records, and interviews with administrative, human resources, and health promotion program personnel. The director of human resources administration at IndyGo and the manager of wellness and benefits at RTS also participated in interviews and provided information for these case studies. In some cases, members of agency staff joined a conversation and/or provided data. Details on the project team’s selection method for the sites included in the study are available in Appendices A and B. In the case of IndyGo, RTS, TARC, and DART, the project team conducted an analysis based on individual-level data to determine if statistically measurable benefits were associated with program participation. LA Metro did not provide individual-level data, so regression modeling was not possible for this location. For the analyses, baseline data were collected from before the comprehensive health and health promotion programs began. Also collected before, during, and after the program were individual records of absenteeism (both sick and personal days taken) and workers’ compensation payments. Measures of participation were collected as well. Specifically, the project team examined the relationship between wellness/health promotion programs (screenings, 5K runs, diet) and improved health outcomes (less absenteeism, fewer sick days) in four sites using linear regression analysis. The results for three sites showed no statistically significant measurable benefit, a finding broadly consistent with past studies. In one loca- tion (Des Moines) the participation effect was statistically significant at the 95% level; it was estimated that participation in the program resulted in a 4-hour decrease in absentee hours. This result was reasonably larger, but based on a small sample so it is unclear if it could be repli- cated or should be used to generalize about effective wellness program interventions. The analyses for TARC (Louisville) and DART (Des Moines) were structured somewhat differently from those for IndyGo (Indianapolis) and RTS (Rochester). For IndyGo and RTS, C H A P T E R 6 Case Studies: Health Promotion Programs

54 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line the control/non-participatory group was based on a structural factor, such as whether an employee was insured or not (IndyGo) or worked at a remote location as opposed to working onsite (RTS). By contrast, the participants at TARC and DART volunteered to take part in well- ness activities and wellness screenings. In these two studies, the records on voluntary partici- pation were used to measure the correlations between outcomes and wellness programs. For IndyGo, RTS, TARC, and DART, the data were tracked so that pre- and post-analysis of effects of participation on absenteeism could be properly conducted. Because data were available on gender, race, and day of hire/termination, participation in these programs could be analyzed, as could rates of turnover and other research questions. The LA Metro case study provided information on the prevalence of health conditions from its insurance companies and detailed aggregate data on wellness program participation records. Individual-level data were not made available on absenteeism or workers’ compensation, however, so a multivariate statistical analysis was not possible. This chapter discusses process-based and data-driven benefits, though the two are not always mutually exclusive. Process-based benefits can include the diversity of the wellness committee, the array of programs, and the flexibility of the schedule. Data-driven benefits can include reduced absenteeism or workers’ compensation claims. This chapter begins with the description of the programs and more process-based benefits of the programs and follows with a discussion of estimated data-driven benefits. The case studies include scalable and sustainable strategies that have been implemented by the transit agencies. The programs have multiple features, including workshops on diet and exercise, biometric screenings, targeted education to avoid common injury types (e.g., musculoskeletal), financial planning, fitness challenges, and onsite gyms. 6.2 IndyGo This case study was developed through emails and discussions with the president of Amalgamated Transit Union (ATU) Local 1070, and the director of employee services for IndyGo. 6.2.1 Background IndyGo is a municipal corporation providing public transportation to the city of Indianapolis and surrounding Marion County, Indiana. The agency operates 31 bus routes throughout the county (IndyGo n.d.). As of 2018, it has approximately 680 employees, of whom more than 500 are members of ATU Local 1070 (Russell 2018). 6.2.2 Program Startup and Development The onsite clinic and wellness program were started on January 1, 2010, as part of a binding arbitration award between IndyGo and ATU Local 1070 in response to a pending premium increase of 46% from IndyGo’s health insurer. The steep increase was the provider’s response to the high cost of IndyGo’s medical claims. To control the increase, IndyGo management (together with the agency’s benefits consultant and with agreement from ATU Local 1070) proposed an onsite clinic and wellness program. Given the agreement to offer the onsite clinic and wellness program, the insurance provider dropped the premium increase from the pending 46% to approximately 20%. The overall savings captured by reducing the increases in insur- ance premiums benefited the program in two ways. As an incentive to participation, the agency used some of the savings to reduce the portion of the insurance premiums paid by participating employees, and additional savings helped fund the program itself.

Case Studies: Health Promotion Programs 55 6.2.3 Work Organization/Work Environment Like many other agencies, the majority of operators (approximately 55%) at IndyGo work split shifts. For many operators, this arrangement has a negative impact on their quality of life. Unless operators invest the time and expense to acquire, transport, and store their own food, having access to healthier food choices can be challenging. Onsite vending machines available in the break rooms were not stocked with healthy options. One of the top priorities of ATU Local 1070 has been to provide adequate restroom access for operators. This quality of life issue can have meaningful consequences, both short- and long-term. Before implementing the wellness program, management and union leaders worked together to address this issue. 6.2.4 Health, Wellness, and Safety Concerns From the perspective of IndyGo management, the main health concerns concerning workers’ compensation are musculoskeletal injuries; slips, trips, and falls; and vehicle accidents. According to the aggregate data from claims reports and onsite clinic data, the top health issues on the personal health side are obesity, hypertension, diabetes, prediabetes, and asthma. To address the work-related incidents and injuries, IndyGo has been incorporating ergonomics and prevention of injury into onboarding and in-service training. The union president expressed that diabetes, sleep apnea, and hypertension are the top health and wellness issues of the represented employees. Obesity is also on the rise among frontline employees, according to the local president. 6.2.5 Program Activities/Elements The IndyGo health and wellness program was made available to employees who have insur- ance through IndyGo. In 2016, approximately 88% of all IndyGo employees were covered under group health insurance. Participation was voluntary but incentivized: If employees participated in the program, they paid half of the premium (15% of the total insurance premium) compared with employees who did not participate (30% of the total insurance premium). Because of the incentive, IndyGo reported that 97% of the employees covered under the group health insurance plan elected to participate in the program (Russell 2018). To maintain their discounts on the health premiums, employees must complete the following annually: a physical, a health risk assessment, a biometric screening, a minimum of four coaching sessions, and a health activity. Some of the physical and educational activities include gardening, a Weight Watchers program, onsite exercise classes, walk–run groups, basketball tournaments, a 5K event for runners and walkers, and financial and nutrition classes. Union leadership stated that the approach has been effective because even though parti- cipants have to complete the requirements, the focus is on self-help and learning how to properly care for your health on your own. The union has been particularly pleased with the level of involvement of the onsite clinic provider because they understand the nature of the jobs performed and have developed relationships with the employees. Participants can get advice and care based specifically on the demands of their jobs. Participation in the program primarily occurs while employees are on the clock. According to the agency, getting employees to participate outside of their shifts is difficult. Efforts have been made to hold events and wellness opportunities in the community, but these activities were not well attended. “It’s a great program. I suffer from a lot of ailments and gain weight very easily. The doctor and nurses at the Activate clinic are very personal. They helped me so much and I have seen real progress. They understand how demanding the job is and our eating habits. They define different alternatives. We have good results; people are getting more conscious about fitness. That’s what you’ll hear from most members.” —ATU Local 1070 Financial Secretary

56 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 6.2.6 Organization The human resources department oversees the onsite clinic and wellness program and all activities related to health program initiatives. IndyGo contracts with a third party that is staffed with two nurse practitioners, a part-time doctor, and medical assistants, and has a wellness committee composed of union and non-union employees that help design new activities and promote the program and initiatives. The program is funded through the IndyGo operating budget, which incorporates funding obtained through agreements with the union and the healthcare insurance provider. The 3-year contract with the current onsite clinic provider costs the transit system approximately $500,000 a year, including staff costs, clinic services (primary and urgent care), and expenses for some prescription drugs (as a one-time fill) (Russell 2018). 6.2.7 Qualitative Program Benefits Although the program did not have strong internal support from frontline workers initially, the president and financial secretary of ATU Local 1070 promoted the program and helped assure workers that information disclosed in the clinic would remain confidential (Russell 2018). Now, agency and union leaders report that there is total support for the program among the employees. Many employees have shared their positive experiences, including being screened for prediabetes or sleep apnea and having access to information about how to improve eating habits and lose weight. 6.2.8 Reported Metrics From 2010–2013, the average cost for health insurance per employee fell from $12,790 to $10,244. Between 2014 and 2017, the insurance provider changed and insurance costs fluctuated. In 2017 (under the new provider) the average insurance cost per employee was $13,004. As shown in Table 29, health claims rose from 2016 to 2017 (fourth column, percentage change) and appeared to be increasing at a similar rate in 2018 (sixth column, percentage change). Additional detailed information on medical claims (e.g., claims broken down by condition or claims dating back before 2015, before the wellness program began) was not received. 6.2.9 Method On June 15, 2018, after preliminary conversations, the project team provided IndyGo with a data use agreement stating that all data—including human resources, payroll, and program participation and other related data—would be used only for the research project, would be handled and protected according to the requirements of the Federal Information Security Management Act (FISMA), and would be destroyed at the end of the research period. Claim Type 2016 a 2017 a PercentageChange January 1– June 30, 2018 Projected Percentage Change b Medical-paid claims $4,257,969 $5,078,484 19.27% $2,538,382 20.0% Prescription-paid claims $1,091,018 $1,494,763 37.01% $791,502 27.1% a Table not adjusted for inflation. The Consumer Price Index (CPI) in 2017 was 1.6% per the U.S. Inflation Calculator; in 2018 it was 1.9%. b Numbers in this column are based on the assumption that the monthly rate in the second half of the year is the same as the monthly rate during the first 6 months of the year. Table 29. Claims and prescriptions reported for IndyGo, 2016–2017.

Case Studies: Health Promotion Programs 57 On June 21, 2018, after a follow-up call with personnel at IndyGo, the project team sent an email requesting the following data: • Excel files (or tab-delimited files) with downloads of the number of personal days and number of sick days with employee names, gender, date of birth, occupational code, and date of hire for 2009–2018 (or whichever historical years were available) for all employees; • Excel files (or tab-delimited files) with downloads of workers’ compensation payments for 2009–2018 with employee names for all employees; • Excel files (or tab-delimited files) with race and employee names for all employees; • Names of participants by year in the health insurance program; and • Names of participants by year in the health wellness program, among those eligible for the health insurance program. IndyGo provided payroll data with individual-level data from 2009 to 2018 on absences, including sick leave, personal leave, family medical leave, and leave without pay, as well as workers’ compensation data from 2012 to 2018. Because IndyGo introduced the health program in 2011, 2010 was established as the baseline year for the analysis, and all requests for data referenced 2010 as the first year. (Based on the initial interview, some early requests were made for 2009 data, but the agency later clarified that the program began in March 2011.) IndyGo further provided insurance information for employees from 2011 to 2018. Using the 97% participation rate in the program among those who carried insurance as a basis, the project team assumed that if employees carried insurance, they participated in the program. No other data were available on participation among those insured. The insurance information was merged with the absentee data based on the employee’s name and birthdate. The data provided 36 categories of job descriptions, with several categories referring to different types of operators (e.g., full-time, part-time), as well as jobs with maintenance, and administrative roles. Employees were categorized as operators, mechanics, and administrative staff based on their job descriptions in the leave data; for example, fixed-route–coach operator and flexible services coach operator were defined as operators. Administrative roles were removed from the analysis because the focus was on the outcomes for frontline employees, which consisted of operators and maintenance staff. For the models, the project team analyzed the full-program effects: comparison of absen- teeism and workers’ compensation measures for 2010 (the baseline year) with measures for 2017 (the last full year of program data) or with the last full year that the employee was at IndyGo before 2017, if the individual’s employment was terminated in 2017 or before. Regression models were run using ordinary least squares to detect any potential correlation between participation in the health program and lower absenteeism. The dependent variable in the models was an overall absentee variable capturing total days of leave, and the inde- pendent variables were participation/insurance (the key explanatory variables) and control variables, including age, race, tenure, gender, and occupation. The regression model was run using alter native dependent variables to measure the robustness of the model and results to different specifications. Two of those alternatives were workers’ compensation dollars and the difference of absenteeism and workers’ compensation before and after the introduction of the health program. 6.2.10 Workforce Characteristics To be included in the analysis, employees had to have been employed with IndyGo for at least 1 full calendar year in 2010 and for 1 full calendar year after the wellness program began in 2011. This qualification applied to 252 records. The workforce under observation was smaller than the total workforce due primarily to missing data and high turnover. In 2010,

58 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line IndyGo had 333 frontline employees. Twenty-one employees were excluded for missing data required in the regression analysis, and 60 employees were excluded because their employ- ment was terminated before the first complete year of the program. This left 252 records avail- able for the analysis. Table 30 presents race, age, and gender breakdowns for the two employee types (operator and maintenance, separate and combined) considered in the analysis. The White population was substantially older than the African-American population: The average age for the 53 White workers was 60.1 years, compared with an average age of 53.6 years for the 220 African-American workers. The men were slightly older than the women, averaging 56.5 years of age for men compared with 52.2 years for women. The maintenance workers were older than the operators, with an average age of 58.5 years compared to 54.7 years, and maintenance workers tended to be male at a higher rate (93.1%) than did operators (56.2%). The analysis examined if outcomes related to absenteeism were related to participation in the program. Thus, the analysis divided the population of frontline employees into two groups: “ever in program” and “never in program.” Table 31 displays the characteristics of these two groups. Based on employees having insurance through IndyGo, the average age of participants in the program was slightly younger (53.7 years) than the average age of non-participants (57.0 years). As Table 31 shows, participants in the program were overwhelmingly operators (only one maintenance worker had been in the program). 6.2.11 Absentee Hours After Program Initiation The data generated from the IndyGo health promotion program provided a wealth of new information in an area where data have been sorely lacking. Figure 5 presents the average annual absentee hours for frontline employees for the 8 years from 2010–2017. The figure illustrates the trend in absentee days, starting with the year before the program began (2010) and extending through the last full calendar year in which data were provided. The graph presents absentee hours over time for all employees (orange line), women (purple), and men Demographic Characteristic Operator Maintenance All Count Percent Age a Count Percent Age a Count Percent Age a African American 191 85.7% 53.9 7 24.1% 50.0 198 78.6% 53.6 White 31 13.9% 59.7 22 75.9% 61.2 53 21.0% 60.1 Other race 1 0.4% 60.0 0 0% N/A 1 0.3% 60.0 Female 87 39.0% 52.5 2 6.9% 48.9 89 35.3% 52.2 Male 136 60.9% 56.2 27 93.1% 59.2 163 64.7% 56.5 Total 223 100.0% 54.7 29 100.0% 58.5 252 100.0% 55.0 a All ages are averages. Table 30. Demographics of IndyGo frontline population, 2010. Demographic Operator Maintenance AllCount Percent Age * Count Percent Age * Count Percent Age * Ever in program 153 68.6% 53.9 1 3.4% 38.6 154 61.1% 53.7 Never in program 70 31.4% 56.4 28 96.6% 59.2 98 38.9% 57.0 Total 223 100.0% 54.7 29 100.0% 58.5 252 100.0% 55.0 * All ages are averages. Table 31. Program participation and age by job category, IndyGo.

Case Studies: Health Promotion Programs 59 (teal), and for African Americans (blue) and Whites (red). Absentee hours were defined as total hours of sick leave, personal leave, and sick unpaid leave. Although year-to-year fluctuations occurred for all six groups, the general trend does not demonstrate much variation. Beginning with an average of 70 hours in 2010, there was a slight increase over the 8-year period to approximately 100 hours at the end (2017), which might reflect an aging workforce. Women on average have slightly higher amount of sick leave than men, which was a trend evident among all the case study populations. Figure 6 shows the trends as plotted for the median annual absentee hours. Figure 7 presents the average annual absentee hours for frontline employees for the eight years from 2010–2017. The graph shows maintenance employees (blue), operator employees (red), and total frontline employees (orange). 6.2.12 Workers’ Compensation Table 32 shows the number of indemnity claims for the years the agency provided— specifically, annual data for frontline employees from 2013 through 2017. These claims could not be matched with individual employees (participants or non-participants). The table 0 20 40 60 80 100 120 140 160 2010 2011 2012 2013 2014 2015 2016 2017 Black or African American White Other Female Male Grand Total Figure 5. Average annual absentee hours, IndyGo frontline employees by race and sex, 2010–2017. 0 10 20 30 40 50 60 70 2010 2011 2012 2013 2014 2015 2016 2017 Black or African American White Female Male Grand Total Figure 6. Median annual absentee hours, IndyGo frontline employees by race and sex, 2010–2017.

60 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line illustrates the variation from year to year in both the number of claims and the average dollar- amount per claim. Figure 8 shows the percentage of (frontline) employees with indemnity claims from 2013 through 2018, including the total of employees with claims (orange), and the percentages for various demographic groups. As discussed above, data on claims before 2013 were not available. The percentage of claims increased over the observed period; thus, there was no evidence of a reduction in claims attributable to the program during this period. The program may have caused a reduction, but other (unobserved) factors would have had to offset that reduction, causing the overall rate to rise. Note that women filed the highest percentage of claims consis- tently throughout the period. 6.2.13 Results Using regression analysis, the project team investigated using several model specifications. The analyses varied the dependent variable, changed the mix of independent variables, and tested several interaction terms. The interaction terms tested how program participation varied by some of the demographic variables. In no case was the coefficient on the effect of program participation statistically significantly different from zero—that is, in no case did participa- tion have a statistically significant effect on health, measured as the change in number of days absent. Variables also were included for operators and maintenance, which would have shown if one occupational group was more likely to have reduced absenteeism days associated with the program than the other group. However, variables in those regressions did not have any statistically significant effects either. 0 20 40 60 80 100 120 2010 2011 2012 2013 2014 2015 2016 2017 Maintenance Operator Grand Total Figure 7. Average annual absentee hours, IndyGo frontline employees by job classification, 2010–2017. Year Sum of Claims Unique Claims Average per Claim 2013 $122,890 125 $983 2014 $228,239 336 $679 2015 $426,234 125 $3,409 2016 $956,551 336 $2,847 2017 $49,534 64 $774 Table 32. Workers’ compensation indemnity claims by year, frontline IndyGo employees, 2013–2017.

Case Studies: Health Promotion Programs 61 Appendix C outlines some of the potential reasons for the lack of significance for the participation variables. In particular, Tables C-1 and C-2 present two regressions that are representative of the variations that were tested, and the corresponding text includes a discus- sion of the analysis. 6.3 RTS This case study was developed with input from the director of well-being and inclusion and the director of people, performance, and development at RTS, and the president of ATU Local 282. 6.3.1 Background RTS is the public transportation agency that provides service to the counties of Monroe, Genesee, Livingston, Ontario, Orleans, Seneca, Wayne, and Wyoming in New York State. The agency serves more than 17 million customers annually and employs more than 900 individuals, of whom approximately 75% are operators and maintenance employees. As the largest subsidiary of the Rochester–Genesee Regional Transportation Authority, RTS has a fleet of 216 buses (of the authority’s total fleet of 404) and has built a reputation for on-time perfor- mance and innovative performance management (Rochester–Genesee Regional Transporta- tion Authority n.d.-c). Approximately two-thirds of RTS employees are based at the agency’s Monroe campus, which is the location of an onsite gym and the hub of the agency’s health promotion activities. The other employees are based at nine offsite locations remote from the Monroe campus and do not have immediate access to the gym. The employees based at the offsite locations have limited access to the agency’s health promotion activities. The data provided by RTS and the Rochester–Genesee Regional Transportation Authority used codes to represent employees at the main locations, including the nine offsite locations: Lift Line, BBS, STS, WATS, WYTS, OTS, CATS, GTC, and LTS. 6.3.2 Program Startup and Development RTS’s health and wellness program, dubbed Healthy U, started in 2011 as a modest and loosely defined program with a focus primarily on physical fitness. It became a more 0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 2013 2013.5 2014 2014.5 2015 2015.5 2016 2016.5 2017 2017.5 2018 Black or African American White Female Male Grand Total Figure 8. Percentage of employees with workers’ compensation indemnity claims, by demographic group, IndyGo frontline employees, 2013–2017.

62 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line developed wellness program in 2013 and 2014, addressing a comprehensive set of goals that were defined in 2014. With healthcare costs skyrocketing and premiums rising both for the agency and the covered employees, RTS understood that it had an opportunity and an obli- gation to help employees. The agency hired a full-time health and wellness coordinator to oversee the newly expanded program. As the program was developed, medical claims data were examined to understand the most prevalent and costly medical conditions. Combining this knowledge with information about the demographics of the frontline employees, RTS staff members crafted the initial focus of the program. The agency conducted a survey in 2014 to understand the needs of transit employees, the types of programs they would be most likely to participate in and benefit from, and the most convenient times to hold events. The agency received 153 responses to the survey. In 2018, RTS conducted a similar survey to gather feedback on the wellness program. The latter survey asked respondents whether they had participated in wellness activities in the past and asked respondents to identify what would motivate them to participate in the future and whether there were any barriers that prevented their participation. This survey found that 52 respondents had participated in previous health promotion activities (RTS 2018). 6.3.3 Work Organization/Work Environment At RTS, almost all operators work split shifts (either two or three shifts). Generally, employees are on the clock between 9 hours and 12 hours, including breaks between runs. The maximum amount of time behind the wheel is 12 hours, however, and the maximum shift time is 15 hours. Bus maintenance requires coverage 24 hours a day, 7 days a week. Approximately 10% of bus technicians work split shifts—two sets of scheduled times within a 7-day span. A tech- nician may work, for example, from 11:00 a.m. to 7:00 p.m. for three days, then from 3:00 p.m. to 11:00 p.m. for the remaining days of the work week. Vacation time is based on accrued personal time, and vacation leave is approved and sched- uled for the entire upcoming year. Every employee also is allowed nine sick time and/or unapproved absences per year. If the number of unapproved absences exceeds nine, employees enter disciplinary action. Operators can apply for approved time off by putting in their name and the requested date(s). As long as the employee has sufficient accrued time to cover the requested leave, approved time off does not count as an unapproved absence (RTS 2018). Shift work and varied schedules have an impact on workers’ access to healthy food and sleep patterns. Employees working overnight shifts have access to vending machines onsite, but due to the hours, the availability of alternative healthy food options is limited in the community. Sleep schedules also can be impacted by working overnights. Many bus cleaners who work overnight shifts also work a second job during the daytime, which can result in added stress, limited access to healthy food and healthcare services or support, and irregular meal times. RTS’s health insurance provider issues annual data showing the prevalence of health condi- tions. The top three conditions for 2017–2018 were hypertension (affecting 25.1% of the insured population), cholesterol disorders (16.8%), and back and neck problems (10.2%). The union president considers sleep apnea, diabetes, hypertension, and muscular issues (primarily back and shoulder) as the primary reasons leading to potential medical disqualification among operators (Chapman, personal communication, 2018). The union also cited anxiety and stress and poor nutrition as the top health and wellness concerns.

Case Studies: Health Promotion Programs 63 6.3.4 Program Activities/Elements Healthy U has promoted healthier behavior and habits among RTS employees by providing a comprehensive set of new offerings and services and changing existing services to align with the goals of the program. Many of the adjustments have focused on food because this is an accessible way to build relationships with employees. The new programs and offerings were designed to be convenient and fun to encourage participation (e.g., short workshops in the break room, bowls of fresh fruit, team activities). The program also prompted changes to regular events and services that employees engage with (e.g., by providing healthier choices in vending machines and at employee events). RTS has made efforts to provide services that fit into the daily schedule of its employees. Agency employees have 24/7 access to a wellness center that includes a gym. Employees also can make individual appointments with a health and wellness coordinator. The health and wellness coordinator works full time, which provides some flexibility for operators and other employees with off-hour shifts. The program also offers vouchers that employees can use to obtain produce from a local farmer’s market at their convenience. Employees’ schedules, which are characterized by working shifts around the clock and on weekends, inhibit their participation in various parts of the wellness program. The wellness team and coordinator have tried to create programs that can be used at any time, with the hope of making it as easy as possible to engage all employees, regardless of what shifts or days they work. There is no feasible way to make the program accessible to everyone all the time, however. RTS promotes the Healthy U program through newsletters, posters and flyers, email blasts, paycheck attachments, and home mailings. Employees also can find information on the agency’s intranet (Rochester Business Journal 2016). One of the most effective ways of promotion is through the support and engagement of the agency’s Wellness Committee, whose members keep their coworkers and teams up to date on activities and events—and encourage their coworkers to participate. From each regional property, the RTS regional manager selects one employee (who may have a personal interest in wellness or be interested in a develop- ment opportunity) to participate as a wellness champion. Wellness champions participate in a monthly conference call to share ideas and collaborate on wellness-related topics, outreach, and events. Wellness champions do not receive extra compensation for their participation. The president of ATU Local 282 helps communicate information about the program to the union’s members. 6.3.5 Organization The People Department (Human Resources Department) manages RTS’s health and well- ness program, which employs the full-time wellness coordinator. The Wellness Committee is staffed by representatives from every division and meets once a month to oversee the program. This committee is made up of 16 employees, including one ATU member, and two representa- tives from the agency’s health insurance provider. Participation in the Wellness Committee is voluntary and members are not compensated extra. The President of ATU Local 282 also is personally involved in many health and wellness events organized by the agency. RTS has recently enacted a “Commitment to Diversity and Inclusion,” which the agency posits will impact the overall health and well-being of the organization and all employees by creating a more inclusive atmosphere that favors respect and relationships. A council of 16 employees, of whom 7 are frontline workers and ATU members, is responsible for carrying out the new effort, working in tandem with the wellness committee. Example of Sustainable, Successfully Implemented Strategy • Connecting around food: • Fresh fruit in breakrooms and common areas; • Snack of the month; • Short workshops on nutrition and cooking; • Healthier vending machine choices; • Catered employee events featuring “good-for-you” options; • Voucher program for local farmer’s market and other onsite experiences.

64 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 6.3.6 Resources The Healthy U program relies on third-party providers and community partners for many of the services offered. RTS funds the program through its operating budget. In fiscal year 2017–2018, the program budget was $24,320, not including the salary for the wellness coor- dinator (Rochester–Genesee Regional Transportation Authority n.d.-a). The budget covers these key categories: blood pressure kiosks onsite; equipment and supplies for the wellness center (onsite fitness facility); health screenings; food for events; promotional items; well- ness initiatives linked to claims management; and other wellness initiatives and employee engagement. For fiscal year 2018–2019, the budget was increased by $17,000 (a substantial 70%) to $41,320. 6.3.7 Qualitative Program Benefits From the perspective of the agency, the wellness program has been a successful endeavor. It has brought the organization together and fostered greater employee engagement. Despite the lack of financial incentives for participation, program engagement and utilization have increased. According to the director of well-being and inclusion, one of the greatest difficulties regarding the participation of operators is scheduling. The majority of RTS bus operators work in shifts with prolonged breaks in between, but the breaks seldom align with planned wellness events. Some success has resulted from efforts to encourage supervisors to communicate with operators and promote the program by word of mouth. According to the union president, operators that have schedules consisting of three shifts participate in wellness events to a lesser extent because of the length of their workdays. Employees with irregular work schedules find it easier to participate in events that are sched- uled on weekends or programs that are available to employees at their discretion (including the produce voucher program). Increased physical activity due to the availability of the gym is the most apparent benefit of the program, though only employees that work at the Rochester campus use it regularly due to the proximity. 6.3.8 Reported Metrics The project team examined statistics from RTS’s health insurance provider (Table 33). As seen in the table, the prevalence rates of most of the major disorders that occur in the transit worker population showed slight increases among RTS’s insured population. Because the aggregate figures provided included administrative workers and covered dependents as well as frontline workers, it was not possible to isolate the effects of participation in the wellness program. Participation in the wellness program may have mitigated increases in prevalence “RTS wants our employees to thrive and live the healthiest lives they can. The RTS Healthy U wellness program fosters a culture of health and well-being within our organization and community by empowering our employees to make healthy lifestyle choices. The strategic initiatives we are implementing for the wellness program will support employees by providing education, resources, support, and access to programs and services that are fun, engaging, and sustainable. Healthy U brings employees together on their wellness journey and celebrates their successes.” —Renee Ellwood, Director of Well-Being and Inclusion Disorder 4 Years Prior Current Change General Population (Excellus) Cholesterol disorder 30.2% 29.0% –1.2% 18.9% Hypertension 38.8% 41.9% 3.1% 23.2% Diabetes 15.4% 16.7% 1.3% 8.1% Back and neck problems 8.5% 12.9% 4.4% 14.9% Depression and anxiety 5.3% 5.9% 0.6% 9.6% Source: Table as provided by RTS via personal communication (Excellus 2018). Table 33. Comparison of rates of major health disorders, RTS insured population to general population, 2012–2017.

Case Studies: Health Promotion Programs 65 among the frontline workers that were part of a more general health trend; however, lacking the necessary granularity in the data, that hypothesis could not be assessed. RTS continues to conduct ongoing review and analysis of the health claims data and monitor wellness initia- tives against claims data (Rochester–Genesee Regional Transportation Authority n.d.-b). In addition to health claims data, new conditions are identified through free, onsite health screenings. RTS seeks to educate and bring awareness to employees about potential health risks and to prevent or manage them. The focus on prevention has resulted in the identifica- tion of more employees with health risks, but this identification has also made it possible for employees to help manage those risks, using the Healthy U wellness program to make healthy lifestyle choices. The program also has focused on the importance of managing health condi- tions and prescriptions, as well as actively using the comprehensive health and wellness benefits provided to employees (e.g., insurance coverage for medical, dental, and vision services, and other employee benefits related to financial wellness and retirement planning). 6.3.9 Method The project team provided RTS with a data use agreement, and data received from RTS associated individuals with their employee ID numbers, thereby protecting their identities. Following conversations with relevant staff members, the project team emailed a list of the absenteeism, workers’ compensation, and demographic data requested. In August 2018, RTS began providing the project team with individual-level payroll data on absences and workers’ compensation. RTS provided absenteeism and workers’ compensation data from 2011 to 2018 for both onsite and offsite employees. Files of employees’ demographic information were provided, as well as hire and termination dates. This information was merged with the absentee data based on the employee ID. Because RTS had indicated that it introduced the health program as a comprehensive program in 2014, 2013 was used as the baseline year for the analysis. Payroll information was made available for more than 1,000 employees who had worked for RTS over the 2010–2017 period. Approximately 650 employees were onsite and had the easiest access to the health program. The entity code “RTS” was used to identify employees who were onsite and had access to the health program, whereas the rest of the employees were combined into a control group of “offsite” employees who were assumed to have limited-to- no-participation in the program. The data provided 282 categories of job descriptions, with several categories referring to different types of operators, maintenance, and administrative roles. Employees were catego- rized using the “Assignment Title” provided with their demographic information. For example, employees with the title bus operator were defined as operators, whereas an employee with the title workforce development manager was defined as administrative. Employees often had multiple assignment titles without a date-of-job change. To determine the job description, the project team selected the last available job title that was not retiree. Trainee was selected as the job title only if it was the only title available. Administrative roles were removed from the analysis, which focused on the outcomes for frontline employees (consisting of operators and maintenance staff). Multiple variables of interest were compared, including use of sick days, unpaid leave, and personal days. At RTS, employees acquire sick leave and personal leave at varying rates based on seniority; up to 120 days of sick leave can be accumulated (Hall, personal communication, 2018). For each variable, the difference in use before and after the introduction of the health pro- gram was examined. Multiple regression and other statistical analyses were run to find a relation- ship between participation in the health program and lower absenteeism.

66 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line In the model, the dependent variable was a total of sick days, unpaid leave, and personal days. The key independent variable was participation in the health program. The other inde- pendent variables controlled for age, race, tenure, gender, and occupation. The regression model also was run using the difference of the dependent variable before and after the intro- duction of the health program as the dependent variable. No statistically significant results were found. Details of the analysis are provided in Appendix A. 6.3.10 Workforce Characteristics In 2011, a limited version of the program was introduced, but the comprehensive version of the program was not rolled out until 2014, so the project team chose 2013 to be the base- line year for this analysis. Of the 574 frontline workers (operators and maintenance) who were employed in 2013, 389 workers (approximately 68%) were based at the main location where the gym and wellness programs were held, whereas 185 workers (32%) were based at remote locations. The project team designated the 389 workers at the main location as the participants because they had greater exposure to the program’s core elements. The 185 offsite employees were considered the control group of non-participants. Table 34 presents the averages for the total population of frontline employees, broken down separately for operators and maintenance employees. The first demographic detail that stands out is the same as for IndyGo: The White popu- lation is substantially older than the African-American population. The average age for the 300 White workers that were operators or in maintenance was 60.2 years, compared with the average age of 53.0 years for African-American workers. Men were slightly older than women, with an average age of 57.1 years compared with 54.3 years. As in Indianapolis, the population of maintenance workers was almost all male (106 out of 108 workers). The analysis method was to examine how outcomes related to absenteeism were related to program participation. Thus, the analysis divided the population of frontline employees into two groups: onsite and offsite. These groups represented the workers who participated in the program and those who did not. The characteristics of the two groups are displayed in Table 35. The average age of offsite operators (61.0 years) exceeded that of onsite operators (54.3 years). The average age of offsite maintenance workers (55.0 years) was only slightly lower than that of onsite maintenance workers (55.8 years); however, the vast majority of maintenance workers were onsite, with 101 of the 108 workers on location at the main campus. Calculating the total Demographic Characteristic Operator All Count Percent Age * Count Percent Age * Count Percent Age * White 237 50.9% 61.0 63 58.3% 57.3 300 52.3% 60.2 African American 183 39.3% 53.1 36 33.3% 52.4 219 38.2% 53.0 Hispanic and Latino 2 0.4% 60.5 0 0.0% 0.0 2 0.3% 60.5 Two or more races 2 0.4% 66.0 0 0.0% 0.0 2 0.3% 66.0 Native American 1 0.2% 41.0 2 1.9% 52.0 3 0.5% 48.3 Asian 41 8.8% 48.6 7 6.5% 58.3 48 8.4% 50.0 Female 117 25.1% 54.3 2 1.9% 53.0 119 20.7% 54.3 Male 349 74.9% 57.6 106 98.1% 55.7 455 79.3% 57.1 All 466 100.0% 56.8 108 100.0% 55.6 574 100.0% 56.5 * All ages are averages. Maintenance Table 34. Demographics of RTS frontline population, 2013.

Case Studies: Health Promotion Programs 67 populations of offsite workers (non-participants) and onsite workers (participants), the offsite workers were older (60.8 years) than the onsite workers (54.7 years). (The calculated numbers do not appear in the table.) 6.3.11 The Program Over Time As with IndyGo, data generated from RTS’s health promotion program has provided new information to assess the patterns of absenteeism of transit workers. Absenteeism days are defined as total hours of sick leave, unpaid sick leave, and paid and unpaid personal leave. Between 2011 and 2017, the total hours taken increased from approximately 40 to 60 hours per year. Figure 9 presents the average annual absentee hours for frontline employees for a 7-year period (2011–2017). The baseline in this analysis is 2013 and the comprehensive program began in 2014, but this case study includes some available data from 2011 when the health promotion program was introduced in a limited form. Figure 9 includes absen- teeism data from the early years of the program, before it was fully established (2011–2013), and from the subsequent years (2014–2017) that reflect absenteeism after the program was fully developed. The data in Figure 9 show that Whites had higher rates of absenteeism than did African Americans and that the rate of absenteeism among women was similar to that of men (not greater, as was the case at IndyGo). The data in Figure 9 have not been controlled for age. Figure 10 shows trends related to absenteeism by job category for operations, maintenance and all workers. As seen in the figure, during the period examined (2011–2017), maintenance workers had a higher average number of hours absent than did operators. Factor Operator Maintenance Offsite Onsite Offsite Onsite Number 178 288 7 101 Percentage 38.2% 61.8% 6.5% 93.5% Average age 61.0 years 54.3 years 55.0 years 55.8 years Table 35. Program status and age of RTS frontline population, 2013. 0 20 40 60 80 100 120 2011 2012 2013 2014 2015 2016 2017 Black or African American White Hispanic or Latino Female Male Grand Total Figure 9. Average annual total absentee hours, RTS frontline employees by demographic characteristics, 2011–2017.

68 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line Figure 11 presents the average annual total of absentee hours for RTS frontline employees for 2011–2017. On average during this 7-year period, onsite employees used fewer sick days then did offsite employees. 6.3.12 Workers’ Compensation Whereas Figures 9, 10, and 11 show trends related to absenteeism, Table 36 uses data provided by RTS to illustrate trends related to workers’ compensation over the same period (2011–2017), although data for 2013 and 2014 were not available. Table 36 presents workers’ compensation indemnity claims for the period and the average cost per unique claim. Table 37 includes the estimated number of days of workers’ compensation paid for all claims and the average number of days per claim. The claim percentage rate in 2011 (before program implementation) was 8%, and the percentage rate also was 8% in 2016–2017, well into the program. The percentage rose to 11% in 2012 but was reduced to 5% in 2015 (the next available year). The linear downward trend may indicate some effect due to the wellness programs, particularly if other (undocumented) factors were working at the same time to increase the percentage. It was not possible to statistically test these possibilities. 0 20 40 60 80 100 120 2011 2012 2013 2014 2015 2016 2017 Maintenance Operator Grand Total Figure 10. Average annual total absentee hours, RTS frontline employees by job classification, 2011–2017. 0 20 40 60 80 100 120 2011 2012 2013 2014 2015 2016 2017 Offsite Onsite Grand Total Figure 11. Average annual total absentee hours, RTS frontline employees by work location (onsite/offsite), 2011–2017.

Case Studies: Health Promotion Programs 69 Total workers’ compensation days were calculated based on the 2017 average wage for 731 RTS operators and maintenance workers of $24.32 and the workers’ compensation payment of 66.67% of that wage to fully disabled workers in the state of New York. 6.3.13 Results Several variations of the linear regression were performed, the results of which are presented in Appendix A. The project team varied the dependent variable (e.g., sick day, total leave days), changed the mix of the independent variables, and tried several interaction terms of program participation (e.g., onsite as interacted with various demographic variables). In no case was the coefficient on the effect of program participation statistically significantly different from zero. Similarly, in no case did participation have a statistically significant effect on health, measured as the change in days absent. Appendix C discusses potential reasons for the lack of significance for the participation variables and Table C-3 presents representative regression results of the variations run, accompanied by analysis. 6.4 TARC This case study was developed with the input of the president of ATU Local 1447 and the benefits manager at TARC. 6.4.1 Background TARC provides public transportation to greater Louisville, Kentucky, and the surrounding counties of Clark and Floyd in Indiana. The agency was founded in 1971 after legislation allowed the use of local funding from city and county governments to operate mass-transit systems (TARC n.d.). Table 36. Workers’ compensation indemnity claims at RTS, 2011–2017. Year Sum of Claims Unique Claims Average Cost per Claim 2011 $77,532 36 $2,154 2012 $225,487 47 $4,798 2013 Unavailable Unavailable Unavailable 2014 Unavailable Unavailable Unavailable 2015 $116,875 29 $4,030 2016 $512,173 46 $11,134 2017 $638,591 50 $12,772 Table 37. Workers’ compensation indemnity claims and calculated absentee days at RTS, 2011–2017. Year Unique Claims Frontline Workers Percentage With Claims Total Indemnity Claims Total Workers’ Compensation Days Average Days per Claim 2011 36 447 8% $77,532 604 16.8 2012 47 447 11% $225,487 1756 37.4 2013 N/A 468 N/A N/A N/A N/A 2014 N/A 531 N/A N/A N/A N/A 2015 29 549 5% $116,875 910 31.4 2016 46 582 8% $512,173 3,988 86.7 2017 50 592 8% $638,591 4,972 99.5

70 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 6.4.2 Program Startup and Development The employee wellness program began in 2015 with the goal of changing workplace culture as prompted by an observed need for smoking cessation programs. The agency was further motivated to start a program that would reduce health insurance claims, which were relatively high. In 2015, TARC began offering smoking cessation classes, bringing together a motivated group of individuals that evolved into a more organized health and wellness committee. 6.4.3 Work Organization/Work Environment Many operators at the agency work split shifts, which can take up a majority of the employee’s time, although breaks can be scheduled that allow for meals or time at the gym. Operators feel that they have time for little else besides resting for the next day. Operators can request specific shifts at three points during the year, when shifts are scheduled. Eligible operators also have the option of working four 10-hour runs and taking weekends off plus one additional day off during the week. Parameters for split runs are governed by the bargaining agreement with the union, and during the period examined by the project team TARC was well under the threshold designated for split runs. From the perspective of the union president, the agency has prioritized restroom access for operators; this issue has improved over time. According to management, the agency has worked to establish ample restroom stops on every route. 6.4.4 Health, Wellness, and Safety Concerns According to the prevalence rates reported by TARC’s health insurance company, the five most prevalent health concerns by number of members (employees and family members) for 2015–2018 were hypertension, hyperlipidemia, back pain, osteoarthritis, and diabetes. In interviews with TARC management, obesity-related diseases were a common concern. TARC reported approximately 15–20 short-term medical disqualifications per year. The disqualifi- cations increased over the period examined, mostly due to non-compliance with sleep apnea requirements. According to the union president, the top health and safety concerns are passenger assaults on operators, operator injury resulting from equipment in the bus or accidents involving the bus, and breathing in harmful fumes. According to the union president, these health concerns are not addressed in the wellness program because they are categorized primarily as “safety” concerns and are dealt with separately under the joint safety committee. (Hamilton, personal communication, 2019). 6.4.5 Program Activities/Elements TARC’s wellness program activities have been based on survey responses from employees indicating the activities they would be interested in. Though the initial program was developed around smoking cessation, this is no longer a primary focus of the program, and was not an item that received interest in the most recent employee survey. Currently, the program consists of events and programs organized around a theme of interest, an annual corporate games weekend, and a boot camp program. Tracking data on participation has been an area of difficulty for the agency, but TARC has seen some success in encouraging participation by offering incentives and prizes to participants. According to the agency, these items are low cost ways to promote participation and camaraderie. TARC has also invested in creating onsite fitness centers at each of the agency’s main facilities, which the agency’s health insurance company has rewarded by issuing a premium refund to the agency and employees. Highest-scoring items from employee interview survey: • Walking to increase physical activity, • Having healthy snacks available for purchase at work, • Increasing my physical activity level, • Participating in “tasting” events, and • Learning about healthier food choices and portions to help manage my weight.

Case Studies: Health Promotion Programs 71 Specific program activities include weekly yoga classes, 5K runs and participant preparation assistance, periodic weight loss/weight maintenance challenges, walking events, and bioscreen- ings. A point system for participation allows employees to earn small prizes, such as exercise accessories, gear, or gift cards. 6.4.6 Organization The employee wellness program is led by a six-person health and wellness committee made up of representatives from TARC’s Human Resources Department and members of ATU Local 1447, including its president, an operator, and a mechanic. The committee meets every other month to determine upcoming program elements and themes. According to the union president, the relationship between labor and management regarding the program is cooperative. The union encourages participation in wellness program events and activities. 6.4.7 Resources The employee wellness program is funded through TARC’s Human Resources Depart- ment. In fiscal year 2018, $10,000 was budgeted for the agency’s fitness centers and wellness program. The wellness program also has relied on the portion of the health insurance premium refund retained by the agency after premium refunds were distributed to the participating employees. 6.4.8 Qualitative Program Benefits The union president said that the program has been effective in promoting physical activity, although it is not clear whether the employees who have participated are those who would already be active independent of the program. Events are primarily attended by the same group of people, and the program has not broadly affected the employee population. Management at TARC noted that the activities promote team building and encourage a more cooperative work environment. Aside from health outcomes, the program sends a message to the employees that health and wellness are priorities for the agency. 6.4.9 Participation Metrics Participation in several of the activities increased from 2017, the program’s first year, to 2018. For example, participants in the corporate games event rose from 25 in 2017 to 43 in 2018, a significant increase. Data from TARC’s health insurance provider also showed a growing level of involvement since the beginning of the transit agency’s wellness program. Participants are given points for reaching certain levels under the “Humana Go” program (blue, bronze, silver, gold, and platinum). Total participation increased from 84% of all health insurance subscribers (not including dependents and spouses) in 2016 to 94% in 2018. 6.4.10 Workforce Characteristics A total of 338 frontline operators and maintenance workers were employed in 2015 (at the time the program was introduced). Following the program’s rollout in 2016, of these 338 workers 13 employees had attended boot camps, 49 employees had a “high” Humana Go level (i.e., bronze, silver, gold, or platinum level), and 54 employees had attended a bio screening.

72 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line The project team selected these participation variables for analysis because they had the highest participation numbers of the numerous activities included in TARC’s health program. Table 38 presents demographic characteristics for both the total population of TARC’s frontline employees and for the agency’s operators and maintenance employees in 2015. As seen in Table 38, the White population was slightly older than the African-American population. The average age for the 108 White workers was 54.1 years, compared with 51.1 years for the 230 African-American workers. Men were slightly older than women, with an average age of 53.7 years for men compared with 49.8 years for women. The table replicates the pattern observed at IndyGo and RTS, where the majority of the maintenance workers were male. The project team used the data from TARC to further examine how outcomes related to absenteeism were related to participation in the program. To be counted, the workforce under observation in the two analyses performed had to have been employed with TARC since 2015, and their employment had to include at least 1 full calendar year during the period 2016–2017. In this case, multiple measures of participation (key independent variables) were used, and analysis was conducted to see if each one individually was associated with a change in absenteeism. Each category of participation was represented by groups with characteristics, as displayed in Table 39. As shown in Table 39, 13 employees participated in boot camps; these participants had a younger average age (45.3 years) compared to the non-participants (52.3 years). Forty-six employees had an elevated (silver-level or gold-level) Humana Go participation status, and Table 38. Demographics of TARC frontline population, 2015. Demographic Characteristic Operator Maintenance All Employees Count Percent Age * Count Percent Age * Count Percent Age * African American 228 80.6% 51.2 2 3.6% 44.0 230 68.0% 51.1 White 55 19.4% 55.6 53 96.4% 52.6 108 32.0% 54.1 Female 135 47.7% 49.8 1 1.8% 54.0 136 40.2% 49.8 Male 148 52.3% 54.1 54 98.2% 52.2 202 59.8% 53.7 Total 283 100.0% 56.8 55 100.0% 55.6 338 100.0% 56.5 * All ages are averages. Table 39. Program participation and age of TARC frontline population, 2016–2017. Program Participation Operator Maintenance All Count Percent Age * Count Percent Age * Count Percent Age * Key independent variable: participation in boot camps Participated in boot camps 4 1.4% 45.3 9 16.4% 52.4 13 3.8% 50.2 Key independent variable: elevated (gold, silver, or platinum) Humana Go status Base Humana Go status 245 86.6% 52.8 47 85.5% 52.8 292 86.4% 52.8 Elevated Humana Go status 38 13.4% 48.4 8 14.5% 51.8 46 13.6% 48.4 Key independent variable: attended bioscreen Did not attend bioscreen 241 85.2% 52.4 45 81.8% 52.7 286 84.6% 52.5 Attended bioscreen 42 14.8% 50.9 10 18.2% 52.3 52 15.4% 50.9 Total 283 100.00% 52.2 55 100.00% 52.6 338 100.00% 52.5 * All ages are averages.

Case Studies: Health Promotion Programs 73 these participants were younger on average (48.4 years) compared to employees who had a base (blue) level of participation (52.8 years). Fifty-two employees participated in bioscreens, and again had a younger average age (50.9 years) than employees who did not participate (52.5 years). In general, the employees who participated in the wellness program activities tended to be younger than those who did not participate. The Humana Go program was sponsored by the insurer. Employees received points for their participation in wellness program activities, including bioscreens. The points were added up to reach defined levels under the Humana Go program, progressing from blue (the base level) through bronze, silver, and gold, to platinum (the highest level). As an incentive to participation, employees also could earn prizes based on the points they accumulated (partici- pation level). 6.4.11 The Program Over Time Figure 12 presents the average annual number of absentee hours for frontline employees over the 4 years from 2015 through 2018. This analysis used 2015 as the baseline year because the comprehensive wellness program began in 2016. Only one pre-program data point was available, so the data shown in Figure 12 should be interpreted cautiously. Absenteeism days were defined as total hours of sick leave, personal leave, and unpaid leave. As the figure shows, the total average annual absentee hours increased from about 45 hours in 2015 to about 60 hours in 2018. It further shows that women had higher rates of absenteeism, which also was seen in other case studies. Figure 13 presents the average number of annual absentee hours for TARC operators and maintenance workers over the same period, compared to the averages for all frontline employees (Grand Total). As seen in Figure 13, operators consistently had a higher average of total annual absentee hours than did maintenance workers. Again, for all frontline workers, the average annual total absentee hours ranged from about 45 hours in 2015 to about 60 hours in 2018. 6.4.12 Workers’ Compensation Table 40 shows the number of indemnity claims by year from 2015–2017, with partial-year information from 2018 (the 4 years provided by the agency). It was not possible to associate claims with the individual/participant in the health claims, so a regression analysis examining the relationship between changes in claims and participation was not conducted. Figure 12. Average annual total absentee hours, TARC frontline employees, 2015–2018. 0 10 20 30 40 50 60 70 80 90 2015 2016 2017 2018 Black or African American White Female Male Grand Total

74 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line Table 40 demonstrates a trend commonly seen across the case studies, which was that indemnity claims were variable and subject to fluctuation due to factors such as a few high claims. In the case of TARC indemnity claims, the table also shows that the number of unique claims is not much higher than the number of employees with claims, indicating that the instance of repeat claimants was not large. 6.4.13 Results Many variations of the linear regression were performed. The project team varied the dependent variable, changed the mix of the independent variables, and tried several interaction terms of program participation (e.g., boot camp participation or Humana Go level interacted with various demographic variables). In no case was the coefficient on the effect of program participation significantly different from zero, and in no case did participation have a statis- tically significant effect on health (here measured as the change in days absent). Appendix C presents the results of the linear regression analysis, and within the appendix Tables C-4 (Humana Go), C-5 (boot camp), and C-6 (bioscreens) present representative regression results of the various models. 6.5 DART This case study was developed with the input of the human resources manager and chief human resources officer for DART, and the president and business agent of ATU Local 441. 0 10 20 30 40 50 60 70 80 90 2015 2016 2017 2018 Operator Maintenance Grand Total Figure 13. Comparing average annual total absentee hours for TARC operators, maintenance workers, and all TARC frontline workers, 2015–2018. Table 40. Workers’ compensation indemnity claims by year, TARC, 2015–2017 and part of 2018. Year Sum of Claims Unique Claims Average Cost per Claim Employees With Claims 2015 $498,767 63 $7,917 58 2016 $458,357 63 $7,276 60 2017 $1,033,219 76 $13,595 69 2018, January–May $260,673 36 $7,241 35 Total $2,251,016 238 $9,458 222

Case Studies: Health Promotion Programs 75 6.5.1 Background DART is the first regional transit authority in Iowa created under state legislation and was approved in 2005. The agency operates the largest transit system in Iowa, providing more than 15,000 trips per day with a fleet of approximately 145 buses. DART is expanding throughout its service area, introducing more express, shuttle, and weekend service hours. DART also has one of the largest vanpool programs in the Midwest, with more than 100 vans (Iowa DOT n.d.). More than 280 individuals are employed at DART, including its fixed-route and paratransit operators, maintenance and facilities staff, and administration (DART n.d.-b). Taking advantage of a change in leadership within both the labor union and the transit agency management, DART has worked to encourage employees to enroll in the existing health savings account plan and make lifestyle changes. In 2017, DART implemented a comprehensive wellness program for all employees. 6.5.2 Program Startup and Development DART’s annual wellness program began in October 2017. Before developing this program, the agency’s only targeted wellness-related activities were biometric screenings and health risk assessments (HRAs) (McMahon, personal communication, 2018). These programs started 2 years before the current wellness program. DART has promoted a rigorous safety program since 2007 and was recognized by APTA in 2011 for its achievements in building a strong safety cul- ture (DART 2011). The development of the wellness program indicates a shift toward a more holistic approach to the health and safety of its employees. The wellness program was begun for several reasons, including a high number of workers’ compensation claims, low morale, and low employee engagement, and to boost awareness of and participation in the existing wellness screening program and HRAs (McMahon, personal communication, 2018). To structure the program to best suit the needs of the employees, a wellness interest survey was given to employees before the program inception. Ninety percent of employees parti- cipated in the survey; the program was designed and budgeted based on their responses (McMahon, personal communication). A total of 201 survey responses (182 complete, 19 partial) were received in which employees identified desired topics, the length of activities, and most convenient times of the day for activities to take place (McMahon, personal communication). 6.5.3 Work Organization/Work Environment The union has worked with management to improve shifts for operators and therefore reduce the impacts of difficult working hours. The majority (53%) of operators work split shifts, arriving at 5:00 a.m. and working until 8:00 a.m. or 9:00 a.m., after which they break until 2:00, then work again until 6:00 p.m. Efforts have been made to reduce the length of the break between shifts. The union has been bargaining for better scheduling and has worked with management on this issue because it helps with worker retention. Maintenance workers have more standard shifts, working 8-hour or 10-hour shifts with a break scheduled midway during the shift. Restroom access for operators has been a longstanding issue. Management adjusted operator routes due to complaints of urinary tract infections caused by not being able to use the rest- room when needed. Recovery time is now spent at the station, so operators have access to the restroom there. Another issue for operators is proper positioning and type of seat. In 2016, DART bought new seats for their buses and allowed operators to choose the model. The agency also redesigned DART Program Elements • Monthly topics incorporated into the wellness program: back care, cold/flu prevention, diabetes, financial wellness, healthy cooking/ eating, heart health, physical activity, sleep management, stress management, and weight management; • All topics chosen based on survey responses indicating employee interests; • Two to three workshops per month (at DART); • One to three wellness challenges per month that focus on making lifestyle changes (outside of DART); • UnityPoint available at main campus or Central Station location once per month for coaching in operator lounge; and • Gifts/prizes based on participation. DART Survey Response: How Long Should Wellness Activities Last? Most employees believe activities should last between 30–60 minutes, depending on the activity. Averaged across all activities, 41.1% of respondents indicated that activities should last 30 minutes; 20.0% of respondents indicated they should last 45 minutes, and 22.9% of respondents indicated they should last 60 minutes.

76 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line the wheelchair securement stations so that they require less bending and stooping and allow more room to maneuver (reducing lower back pain). When operators have specific complaints about the seat, they are addressed. Often this is done by readjusting the seat or teaching the operator how to do so. The agency also implemented job offer testing to make sure that opera- tors are physically able to do all functional aspects of the position. Approximately 65%–70% of all frontline employees participate in the agency’s health insurance plan. DART requires an annual bioscreening for every employee enrolled in the health insurance plan. 6.5.4 Health, Wellness, and Safety Concerns The union stated that the most prevalent health concerns among its members were chronic pain from the demands of the job (e.g., back pain, injuries resulting from repetitive motion); high blood pressure; and metabolic disease (e.g., diabetes). The agency had a slightly different perception of the top health and safety issues, stating that the top three were weight management, cardiovascular health, and effects of the job (e.g., ergonomics/fatigue/stress management). The agency stated that their rates of medical disqualification among operators were low, but among those that had been disqualified, the primary reasons were diabetes and soft-tissue injuries, usually occurring in the shoulder due to repetitive movement. 6.5.5 Program Activities/Elements According to DART, the program does not focus on any one aspect of health and wellness but rather on caring for the whole person. To that end, the program is multifaceted, incorporating many different topics and methods of approach. DART has engaged insurance providers, financial planners, and registered nurses to deliver workshops and provide coaching and advice to participants (McMahon, personal communication, 2018). A monthly theme is chosen that corresponds with the interests recorded by employees in the initial survey. To complement the theme, two to three monthly workshops are given at DART, as well as one to three wellness challenges that encourage participants to make lifestyle changes. Participation is incentivized with gifts and prizes ranging from sports equipment to gift certificates. Rewards are given for attending workshops and completing the monthly wellness challenges. Participants receive a reward based on the tier they have reached at the end of the program: Tier 1 is reached by attending three workshops and completing three challenges; Tier 2 is reached by attending six workshops and completing six challenges; and Tier 3 is reached by those who attend all workshops and complete all challenges (McMahon, personal communication, 2018). Outside of the events organized as part of the program, the agency has implemented several policies to improve the work environment. DART has created a new vending program so that fruit, vegetables, eggs, and protein bars are available instead of the more common snacks found in vending machines. The agency also hired specialists to analyze the buses and create cards illustrating the stretches appropriate for operators and their environment. Frontline employees are not paid for the time they spend at wellness events. This has caused some reluctance among operators and maintainers to attend events. Administrative employees attend the events during their workday, and are therefore being paid for their time. 6.5.6 Organization The wellness program relies on the planning and support of a seven-member wellness committee. Positions are open to all departments within DART. The committee meets every month to prepare for the following month and make changes and adjustments to the program as needed. Currently, the committee is staffed by the human resources manager, an operations DART Survey Response: Topics of Interest • Back care, • Cold/flu prevention, • Diabetes, • Financial wellness, • Healthy cooking/eating, • Heart health, • Physical activity, • Sleep management, • Stress management, • Weight management, • Men’s and women’s health, and • Understanding medical insurance and other benefits offered at DART. DART Wellness Committee • Seven members, • Committee members from all departments, and • Monthly meeting to prepare for next month and make changes/ adjustments.

Case Studies: Health Promotion Programs 77 instructor, two fixed-route operators, a maintenance employee, an operations supervisor, and a transit planner (McMahon, personal communication, 2018). The wellness committee and the program have the support and participation of the local union thanks in part to the member- ship of its president, a fixed-route operator, on the wellness committee (McMahon, personal communication, 2018). 6.5.7 Resources DART’s wellness program has a relatively low budget (approximately $5,000 annually) and has relied on existing staff to manage the program rather than hiring dedicated staff. For 2017, approximately half of the budget was used for workshops and the other half for the purchasing of incentives. No additional major capital expenditures have been made. Instead, DART has used existing resources to provide programming. Several workshops have been provided at no cost to DART through leveraging connections with wellness organizations and professionals. 6.5.8 Qualitative Program Benefits Behavioral and cultural shifts have occurred both within the management of DART and within the employee community. A new leadership approach, brought about by a transition in management positions, has been instrumental in changing the environment and focus of the agency. DART appointed a new chief operating officer in October 2015 and a new chief human resources officer in December 2016 (DART n.d.-a). Within the employee community, the inclusion of influential individuals on the wellness committee has been an important component to foster a sense of ownership of the program. There is a focus on the personal participation and commitment to life changes of the committee members. The administration has taken the feedback received at the monthly wellness committee meetings and used it to structure the program and increased the budget for next year of the program based on the input of the wellness committee (McMahon, personal communication, 2018). Participation in the HRA was approximately 20% before the start of the wellness program because of workforce resistance to the biometrics screening, which was a requirement for being enrolled in the agency health insurance plan. Following the start of the program in October 2017, 100% of the agency’s employees participated in the subsequent HRA, which occurred the next month. DART recognized that a lack of clarity about whether the HRA was a required part of the bioscreening contributed to the initially low participation rate. Among the employees, some fear also had existed about what the results of the HRA would be used for. The start of the wellness program prompted more discussion with union leadership and with the employees in general, which led to a shift in perception and an increase in engagement, which was the most important and effective change (McMahon, personal communication, 2018). Despite these successes, management acknowledges that other elements of the wellness program have not reached all employees. Although events were held at different times of day and days of the week in an attempt to boost participation, scheduling remained an issue. The employees who did attend came to many of the events. The small percentage of employees who were very active in the program got the most benefit. From the perspective of the union, the program was beneficial in raising awareness of health issues and there was a general sentiment that it was a good idea. Most employees lacked a will- ingness to participate long-term in the program, however. Frontline employees were asked to attend program events in their free time while administrative employees were often on the clock during events; this created some resentment among frontline employees and exacerbated

78 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line problems of participation. Participation increased when incentives were offered, but the effect of the incentives dwindled over time. Issues related to participation were difficult to address given the varying shifts of frontline workers, particularly operators. The types of shifts that employees worked had an impact on how they engaged with the wellness program. Operators were more likely to participate in the scheduled events (presumably because these events fit into their breaks between shifts), whereas maintainers/mechanics used the onsite gym at a higher rate. After running for 9 months, the wellness program discontinued. Due to several agency staff members leaving who had been instrumental in the vision for the program, the committee was dissolved and no more regular events were scheduled. 6.5.9 Reported Metrics Participation data were collected and recorded for each event (McMahon, personal commu- nication, 2018). The goal for participation in the first year of the wellness program was 30% of employees. Actual participation, measured as having attended at least one activity/workshop, was around 42% of employees. Participation in the HRA and biometrics screenings increased from 20% before the start of the program to 100% in the month following the start of the program (McMahon, personal communication, 2018). Although the program was too brief to be able to measure changes in other metrics, such as workers’ compensation claims and absenteeism, program staff has continued to collect data to help assess the effectiveness of the program. 6.5.10 Workforce Characteristics A total of 245 frontline workers (operators and maintenance) were employed with DART at the beginning of 2016, a year before the program started in 2017. Table 41 presents demo- graphic information for the total population of frontline employees and separate break downs for the operators and maintenance employees. Unlike the other case studies, information on age at the individual level was not provided by DART. Compared to some populations in the other case studies, a larger share of this workforce (84.9%) was male. As in the other agencies, the majority of maintenance workers were male. The analysis method was to examine if and how outcomes related to absenteeism were related to participation in the program. Thus, the analysis divided the population of frontline employees into two groups: those who were recorded as having participated in at least one activity Demographic Characteristic * Operator Maintenance All Count Percent Count Percent Count Percent Asian 9 4.4% 3 7.1% 12 4.9% African American 64 31.5% 13 31.0% 77 31.4% Hispanic or Latino 14 6.9% 8 19.1% 22 9.0% Two or more races 1 0.5% 1 2.4% 2 0.8% White 115 56.7% 17 40.5% 132 53.9% Female 36 17.7% 1 2.4% 37 15.1% Male 167 82.3% 41 97.6% 208 84.9% All 203 100.0% 42 100.0% 245 100.0% * Age-related information at the individual level was unavailable for this case study. Table 41. Demographics of DART frontline population, 2016.

Case Studies: Health Promotion Programs 79 and those who were recorded as having participated in no activities. The characteristics of these two groups are displayed in Table 42. The activities included a series of workshops and wellness challenges. As Table 42 demonstrates, 16 employees (out of a total of 245) were recorded by human resources as having participated in at least one activity. Many of the individuals who participated in at least one activity participated in multiple activities. This analysis did not account for marginal gains associated with participation in multiple activities. 6.5.11 The Program Over Time Figure 14 presents the average number of annual absentee hours for DART frontline employees for a 3-year period (2016–2018). Absenteeism hours were defined based on total hours of sick leave, personal leave, and unpaid leave. Figures 14, 15, 16, and 17 show absentee days over time by demographic characteristics and by job classification. A full year of information was not available for 2018, so for 2018 the full year was estimated by comparing the available months with the previous year and assuming that the difference in hours remained the same between the first and last six months of 2017 and 2018. Figure 15 presents the median annual absentee hours for race and sex. Figure 16 presents the average annual absentee hours for DART frontline employees divided by job type over the same 3-year period (2016–2018). Figure 17 presents the absentee hours over time for all employees and those that participated or did not participate in any activities. On average, employees who participated in any activities Program Participation Operator Maintenance AllCount Percent Count Percent Count Percent Did not participate 191 94.1% 38 90.5% 229 93.5% Participated in at least one activity 12 5.9% 4 9.5% 16 6.5% All 203 100.0% 42 100.0% 245 100.0% Table 42. Program participation of DART frontline population, 2016. 0 50 100 150 200 2016 2017 2018 White Female Hispanic or Latino Male Black or African American Other Grand Total Figure 14. Average annual total absentee hours of DART frontline employees by demographic characteristics, 2016–2018.

80 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line Figure 15. Median annual total absentee hours of DART frontline employees by race and sex, 2016–2018. 0 20 40 60 80 100 120 140 160 2016 2017 2018 Black or African American White Female Male Grand Total Figure 16. Average annual total absentee hours of DART frontline employees by job classification, 2016–2018. 0 20 40 60 80 100 120 140 160 180 2016 2017 2018 Maintenance Operator Grand Total Figure 17. Total absentee hours, DART frontline employees, 2016–2018. 0 20 40 60 80 100 120 140 2016 2017 2018 No Participation Participated in Activities Grand Total

Case Studies: Health Promotion Programs 81 used fewer sick days than did non-participating employees; however, because only 16 employees are recorded as participating in any activities, this is probably a case of self-selection bias. 6.5.12 Results A set of 115 observations were available to test for whether program participation had an effect on health. The principal regression model was used to examine the relationship between program participation and absentee hours (see Table 43). The model included controls for race, gender, and type of employee (mechanic or operator). The coefficient estimate of –3.9 was statistically significant at the 95% confidence level. Thus, the project team estimated parti cipation in the program resulted in a 4-hour decrease in absentee hours. Further, race was found to be statistically significant at the 95% confidence level. Specifically, if an employee was White, then absentee hours decreased by 16 hours. No other variable was statistically significant. Because the sample of workers was small—only 12 operators and 4 mechanics participated in at least one activity—the results may be meaningful, but should be interpreted with caution. The results from this model demonstrate that it is possible to find an impact of a wellness program on one of the measures (absentee hours) that often is available at transit agencies. Other agencies may be able to use this approach to evaluate the effectiveness of their wellness programs. 6.6 LA Metro This case study was developed through emails and discussions with the International Union of Sheet, Metal, Air, Rail and Transportation Workers (SMART)–Metropolitan Transportation Authority (MTA) wellness manager and the vice-general chairman of SMART Local 1565. 6.6.1 Background LA Metro serves the 9.6 million residents of Los Angeles County, California, with 165 bus routes and a fleet of 2,308 buses alongside four light rail and two subway lines. Bus and rail operators at LA Metro totaled 4,397 employees in 2018. These occupations were represented by the United Transportation Union (UTU) until 2008, when the UTU merged with SMART. LA Metro also employs 2,370 mechanics, who are represented by the ATU. There are 9,817 total full-time employees at LA Metro. Together, SMART and the MTA manage a trust fund that administers benefits for bus and light rail operators. Ordinary Least Squares: Change in Hours Estimate t-Stat Intercept 38.0 3.60 Participation -3.9 -2.13 Male -5.9 -0.55 White -16.2 -2.32 Mechanic -3.5 -0.40 Observations 115.0 -- R2 0.078 -- Adjusted R2 0.046 -- Table 43. Effect of program participation on absentee hours, DART frontline employees, 2016–2017.

82 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 6.6.2 Program Startup and Development In 2006, LA Metro piloted a health and wellness pilot program at two locations. The agency started the pilot to produce positive effects on absenteeism and workers’ compensation claims. At the end of the pilot program in 2009, LA Metro determined that it did not have the resources to continue to fund the program long-term; however, the value of the program had been recognized and the SMART-MTA trust fund stepped in to manage a permanent program. The program was expanded to 24 locations, including all of the main facilities. 6.6.3 Work Organization/Work Environment Currently, almost 50% of operators work split shifts, with the remainder split evenly between operators who work three shifts and those who work more traditional hours. Because of the demands of their schedules, fatigue can be an issue preventing operators from attending wellness program events. This type of schedule also can be seen as a benefit, however, because operators can use their breaks between shifts as an opportunity to rest, exercise, and/or participate in wellness activities. Since 2017, SMART has worked with the University of California, Irvine, to assess the workplace and job tasks that positively and negatively impact employees’ health and behaviors. The health program plans to use the findings from the university assessment to create program- ming to improve the overall health of employees and their families. The close attention to employees has helped uncover issues that can be resolved by influencing positive changes in corporate culture, policies, and procedures at LA Metro (e.g., schedule changes). 6.6.4 Health, Wellness, and Safety Concerns According to the SMART-MTA Wellness Program Strategic Plan 2018–2020, diabetes, hyper- tension, and cancer are targeted for disease management programs. The vice-general chairman at SMART cited diabetes, high blood pressure/hypertension, and stress as the top three health and safety issues with which the union and its members are most concerned. He shared that stress contributes to many of the health issues that operators suffer from, such as heart condi- tions and sleep apnea, which are causes for medical disqualification of operators, though the instances are low (Wormley, personal communication, 2019). 6.6.5 Program Activities/Elements The primary focus of the health and wellness program is to assist operators, but all employees, regardless of union affiliation, can participate. One program feature cited by the agency and union as leading to its success is the use of ambassadors. Ambassadors are selected from among the frontline workers to promote the wellness program. Each location has an ambassador, and large locations may have multiple ambassadors. Most locations have two wellness ambassadors from SMART (usually a main and an alternate). On specified days (called Wellness Wednesdays), the wellness ambassadors are given 8 hours of release time to engage employees in program activities. Ambassadors also are given hours of release time for offsite events, which are primarily weekend events. Compensation for ambassadors’ time spent on wellness program duties is covered by the MTA. LA Metro’s wellness program runs year-round and features disease management and edu- cation, seminars and table topics, fitness challenges, health fairs and screenings, free family sporting events, and a monthly wellness newsletter. Each year, eight health fairs are held at different facilities on a rotating schedule with the result that over 3 years, all locations hold a

Case Studies: Health Promotion Programs 83 health fair. Wellness activities occur mainly on Wednesdays and are scheduled to coincide with operator breaks between split shifts. The wellness program also has an incentivized weight loss program, called the Metrofit Club. The program is optional and requires a commitment of 10–12 weeks. Participants weigh in every other week with their wellness ambassador and receive assistance in their efforts through education on calculating caloric intake, recipe preparation, and basic nutrition. The program is incentivized with monetary rewards of up to $100 for losing a certain percentage of body weight. A concerted effort has been made to promote LA Metro’s wellness program. This has been done in several ways, including the presence of wellness ambassadors; union, employer, and health plan communication channels; incentives, rewards, kickoff events, challenges, and contests; a consistent theme and key messages; and mail, posters, email, newsletters, and social media marketing and testimonials. 6.6.6 Program Organization The health and wellness program is managed by a full-time coordinator. A health and wellness committee also provides input on programming and goals. The committee meets quarterly, is chaired by the wellness coordinator, and is represented equally by staff and labor members, though two unions working with LA Metro are not represented on the committee (the ATU and the Teamsters Union, which represents security guards). SMART is working toward a goal of including the Teamsters Union and the ATU on the committee, representing mechanics. Ambassadors are chosen jointly by union leadership and management. Every January, the ambassador roles and responsibilities are reviewed, and ambassadors are asked if they want to renew their contract. Training for new ambassadors occurs every quarter. 6.6.7 Program Resources Program costs, not including ambassador pay and the salary of the wellness program manager, amount to approximately $55,000 annually. Health insurance providers contribute to the budget as part of the services offered to employees in exchange for premiums; however, the insur- ance provider does not control the program fund itself. A union trust fund covers the ambas- sador pay (about $275,000 annually) and also covers the salary of the wellness program manager. 6.6.8 Qualitative Program Benefits The project team’s analysis indicated that the pilot program produced benefits. Injury- related claims decreased at some locations, and employees reported better sleep, weight loss, and reduced stress. Participation was tracked by employee badge number and showed that 382 employees participated in some element of the program during the pilot. Since 2009, the expanded program has seen increased levels of participation. Between 2009 and 2012, long-term goals of the program were to reach 10% partici pation and limit health insurance premium rate increases to no more than 5%. Increased partici- pation in the expanded program meant that more employees accessed services covered by the health insurance provider, which led to higher premium rates. Although the increased participation was a positive step, it negatively impacted the premium; for this reason, the well- ness committee changed the goal respecting premiums to maintaining a cost “less than the Southern California healthcare trends.” Program Promotion • Wellness ambassadors; • Use of all communication channels (union, employer, and health plan); • Incentives, rewards, kick-off events, challenges, and contests; • Consistent theme, key messages; and • Mail, posters, email, newsletters, social media, and testimonials.

84 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line SMART uses program data from its health insurance provider to tailor the program and counter cost trends. For example, high numbers of emergency room (ER) visits led to program education on how to avoid using the ER by scheduling appointments and going first to primary care. Results from biometrics screenings performed at the health fairs and data from LA Metro on employee metrics also are used to inform programmatic elements. Results are communicated in a newsletter for members with highlights of the changes in different measures. The program has resulted in policy changes that signify management and union willingness to work together toward the health of employees and ensure that the program receives the proper support and attention. When the program first started and the concept of well- ness ambassadors was introduced, management at LA Metro agreed to provide time off for the ambassadors’ participation in Wellness Wednesday activities. As the program progressed, wellness ambassadors were given paid time for Wellness Wednesdays, and eventually were given paid time off for events outside of work hours, including weekend events. This shift has raised the status of wellness ambassadors and the program generally. According to the program coordinator, the employees’ attitudes toward the program have changed from indifference to more overtly positive sentiments. Employees actively seek out elements of the program and are more willing to provide their success stories, which are published in the wellness newsletter. Union leadership expressed the view that members are genuinely excited about the program and appreciate the involvement of the union and management because it shows that both the union and management have taken a concern in the operators’ health. 6.6.9 Reported Metrics For this analysis, participation was defined as a person attending at least one event within a year. From 2012 through 2017, participation data from LA Metro showed generally positive trends, rising to 38% by 2014 and remaining close to that percentage in later years (Figure 18). Through the Metrofit Club, SMART has tracked the weight loss of participating employees. Figure 19 shows a peak in pounds lost in 2014, after which the amount of weight lost declined in 2015 and 2016. The drop-off may not be a negative trend, however, as the amount of weight lost in 2014 might mean that many participants had already reached or were approaching a healthy weight. Figure 20 shows the number of health club participants per year. The peak was in 2014 at 584 participants. There was a drop-off in 2016, but a slight increase in 2017 brought the number 38%37%38%38% 33% 28% 0% 5% 10% 15% 20% 25% 30% 35% 40% 201720162015201420132012 Figure 18. Participation in health program as a percentage of total LA Metro employee population, 2012–2017.

Case Studies: Health Promotion Programs 85 of participants back up to 446. The pattern seems to be fairly stable and all other years were higher than the initial year of 2012. Data from LA Metro was only provided in the aggregate, so the project team was unable to conduct regression modeling as was done with the other case studies. The information learned from this case study was based on LA Metro’s reports of employee participation in the activities and the overall weight lost by employees, but could not be correlated with outcomes such as absenteeism or controlled for race, gender, or type of position. 6.7 Summary of Case Studies The work organization and environment at each case study location was unique, and each agency faced different health, wellness, and safety challenges. Many commonalities were found across the locations, however: For example, at all five locations, the majority of bus operators worked split shifts, and some operators worked irregular schedules. The varied scheduling patterns impacted operators’ access to healthy food and their sleep patterns, and limited their ability to participate in certain health and wellness program activities. 6.7.1 Program Development and Work Environment The health and wellness programs examined were developed for various reasons and to meet various needs. For example, IndyGo added an onsite clinic as a way to avoid steep insurance premium increases. RTS began with a focus on physical fitness, but added more goals after several years, eventually hiring a full-time health and wellness coordinator. TARC’s 1,500 1,345 1,580 2,039 1,799 1,162 0 500 1000 1500 2000 2500 201720162015201420132012 Po un ds Figure 19. Weight lost per year (in pounds), Metrofit Club participants, 2012–2017. 446420 537 584564 305 0 100 200 300 400 500 600 700 201720162015201420132012 Figure 20. Number of Metrofit Club participants per year, 2012–2017.

86 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line initial focus was on smoking cessation, but the program was expanded to include more general wellness goals. DART encouraged employees to take advantage of all existing employee benefit programs, including a health savings account, and implemented a comprehensive wellness program for all employees. LA Metro’s program began as a pilot in two locations and expanded to 24 locations. At all the sites, at least half of the operators worked split shifts. This presented some chal- lenges for staff, including accessing healthy food choices and finding time for regular exercise. Irregular shifts also contributed to sleep deprivation. An issue emphasized at most sites by staff and union representatives was restroom access. 6.7.2 Health, Wellness, and Safety Concerns Comparing the top three health, wellness, and safety concerns expressed by management and labor representatives and examining insurance claims data, the project team found hyper- tension, musculoskeletal injuries (back and neck pain), and diabetes to be the most commonly found concerns for frontline transit workers across the locations (Table 44). Other areas of concern included sleep apnea, cardiovascular diseases (heart conditions), injuries from bus accidents, obesity, stress/fatigue, and cholesterol disorders (hyperlipidemia). Table 44 lists the top three health issues for each of the health and wellness programs discussed in the case studies and breaks down each issue by three sources: management, labor, and claims data. Not all locations provided data from all three sources. In several cases, management used analysis from insurance claims data to respond to the question about their top health, wellness, and safety concerns. At all five case study locations, labor listed diabetes as a major concern—indeed, in two of the five locations, it was the top concern. Hypertension also was named by labor in four of the five agency locations. Claims data added obesity (including hyperlipidemia) and back pain to the list of top health issues. Management, on the other hand, was more concerned with musculoskeletal injuries, weight management/cardiovascular health, and vehicular accidents. Figure 21 graphs the information presented in Table 44. Again, the most commonly mentioned issue was hypertension, followed by diabetes and musculoskeletal injuries. Areas with only one mention were included in the “Other” category. The distribution of concerns in Figure 21 Program Constituent Priority of Health/Safety Concern Primary Secondary Tertiary IndyGo Management Musculoskeletal injuries Slips, trips, and falls Vehicle accidents Labor Diabetes Sleep apnea Hypertension Claims data Obesity Hypertension Diabetes RTS Labor Sleep apnea Diabetes HypertensionClaims data Hypertension Cholesterol disorders Back and neck problems TARC Labor Operator assault Operator injury from accidents Breathing in harmful fumes Claims data Hypertension Hyperlipidemia Back pain DART Management Weight management Cardiovascular health Ergonomics/fatigue/stress management Labor Chronic pain from the job Hypertension Metabolic disease (e.g., diabetes) LA Metro Joint trust fund Diabetes Hypertension CancerLabor Diabetes Hypertension Stress Table 44. Comparison of top three health, wellness, and safety concerns at five case study locations.

Case Studies: Health Promotion Programs 87 broadly follows the data presented in Chapter 4 regarding the most prevalent health and safety issues for transit workers, with other key conditions also represented. Given the variations in data-supported or perceived health and wellness concerns, program design elements such as activities offered, facility needs, incentives for participation, staffing, organization of committees, and selection of champions were distinct from location to location. Chapter 7 presents process-driven strategies based on these case studies that transit systems can use to maximize program effectiveness. 6.7.3 Program Activities and Elements The programs offered various voluntary activities to employees, though it was common to provide incentives for participation. At IndyGo, participants were required to undergo a physical, health assessment, biometric screening, a minimum of four coaching sessions, and participate in a health activity to qualify for an insurance discount. Health activities might include gardening, Weight Watchers, exercise classes, walk–run groups, 5Ks, basketball tournaments, and/or financial or nutrition classes. RTS offered short workshops onsite, fresh fruit, team activities, different choices in their vending machines, blood pressure kiosks, health screenings, and a wellness center that includes a gym. TARC’s program began with a focus on smoking cessation but later expanded to provide events and programs organized around themes of interest, an annual corporate games week- end, and a fitness-oriented boot camp. The agency has offered some incentives and prizes to participants, but nothing systematic. TARC has provided its employees access to two onsite fitness centers, where they can participate in weekly yoga classes, 5K runs and participant preparation assistance, periodic weight loss/weight maintenance challenges, walking events, and bioscreens. Figure 21. Most common health, wellness, and safety concerns at five case study locations.

88 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line DART’s program did not focus on any one aspect of health and wellness but had a different theme each month that corresponds with the interests recorded by employees in the initial survey. DART has offered two to three workshops and one to three wellness challenges every month. Rewards were given for attending workshops. LA Metro has used wellness ambassadors and provided incentives, rewards, kickoff events, challenges, and contests. The wellness program featured disease management and education, seminars and table topics, fitness challenges, health fairs and screenings, free family sporting events, and a monthly wellness newsletter. Following a rotating schedule, eight annual fairs were held at different facilities so that, over 3 years, all locations had held a health fair. Wellness activities were scheduled to coincide with operator breaks between split shifts. The wellness program also had an incentivized weight loss program. 6.7.4 Organization Most programs were overseen by human resources departments and used third-party vendors to provide services. Several programs had full-time coordinators and volunteers (or paid employees) who served as wellness “coordinators” or “ambassadors.” The funding came from a mix of operating budgets, and agencies were able to detail staff who were already employed with the agency to serve the programs. All the sites examined had a wellness committee that was staffed with a mix of management, union representatives, and frontline staff. Committees met regularly and helped determine the activities and goals of the programs. These programs worked best when there was a cooperative relationship between management and the union. The programs demonstrated a wide range of budgets and operating processes. The best-funded of the case studies was IndyGo, which staffed a clinic with two nurse practitioners, a part-time doctor, and medical assistants. During the assessed period, IndyGo operated with a budget of $500,000 per year. RTS employed one full-time wellness coordinator and funded the program through the agency’s operating budget, using third-party vendors, spending approximately $41,000 per year. TARC’s program was funded by the agency’s human resources office with a budget of approximately $10,000 per year, though the program received additional funds via a premium refund from their health insurance carrier. DART had a relatively low budget of approximately $5,000 annually. Dart relied on existing staff members to manage the program rather than hiring dedicated personnel. Finally, LA Metro spent approximately $55,000 annually, not including the salary for the program coordinator. The health insurance provider contributed to the program budget through a negotiated premium arrangement, though the fund itself was not controlled by the health insurance provider. A union trust fund covered the ambassadors’ pay and the salary of the wellness program manager. 6.7.5 Workforce Characteristics Overall, a racial and gender divide was evident based on job roles. The majority of operators were male, but some gender diversity could be found, with one site having a male population of “only” 52.3% (see Table 45). Maintenance workers were overwhelmingly male, with no site lower than 93%. At all sites, at least three-quarters of maintenance employees were White. The demographics of the populations that are eligible or participate in the wellness programs can help agencies decide on how to focus their activities and how to market them effectively. Figure 22 shows the annual total average absentee hours for each of the case study sites. A great deal of variability can be seen across the agencies, which leads to the conclusion that each must be considered in a local context. Absenteeism seems to be a much greater issue in

Case Studies: Health Promotion Programs 89 some places than others: DART, in particular, experienced such high rates that it is possible to suspect some data discrepancy may explain it, though our discussions with the agency did not suggest this. IndyGo experienced a fairly steady rise in absenteeism beginning in 2014, which might be attributable to a structural change. RTS and TARC have more level numbers, but also seem to have experienced slight rises in absentee hours. This issue is one that agencies will want to continue to monitor. Although absenteeism seems like a good outcome variable for evaluation, it is open to many potential causes that a wellness program will not be able to address. 6.7.6 Conclusions The newly available primary source employee data from this study has provided informa- tive descriptive statistics and statistical results. Details have been included about how pro- grams were developed, the organizing process, and the services and activities offered by each site. Where possible, the project team gathered individual-level data on workforce character- istics, participation rates, and program metrics. The metrics gathered included claims data, data on specific disorders, prescription claims, absentee hours, and workers’ compensation claims. These data have provided a big picture understanding of workforce patterns—and how variable they are. The data examined in this chapter adds to findings from the literature review on the effective- ness of health promotion programs. Although these studies may not have produced measurable Agency Operator MaintenanceBlack Male Age a Black Male Age a IndyGo 85.7% 60.9% 54.7 24.1% 93.1% 58.5 RTS 39.3% 74.9% 56.8 33.3% 98.1% 55.6 TARC 80.6% 52.3% 56.8 3.6% 98.2% 55.6 DART 31.5% 82.3% Unavailable 31.0% 97.6% Unavailable LA Metro b Unavailable Unavailable Unavailable Unavailable Unavailable Unavailable a All ages are averages. b LA Metro did not share individual-level data. Table 45. Summary of wellness program participant characteristics. Figure 22. Comparison of average annual absentee hours across sites. 0 20 40 60 80 100 120 140 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 INDY GO RTS TARC DART

90 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line effects that translate to quantifiable cost savings for agencies, the absence of concrete statistical evidence does not mean the cases lack substantial value. The data that was collected and analyzed adds a host of new information on employee patterns of absence/sick leave and how it relates to participation in health and wellness programs among different segments of the employee population. The project team could not identify a direct relationship between the programs offered and the outcomes examined, but the process followed offers a good way to understand how agencies may undertake such evaluations regarding their own programs. Having clear data available on participants, what programs they have participated in, and for how long, could make future research easier to undertake and interpret.

Transit workers experience more health and safety problems than the general workforce, primarily as a result of a combination of physical demands, environmental factors, and stresses related to their jobs.

The TRB Transit Cooperative Research Program's TCRP Research Report 217: Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line focuses on the prevalence of these conditions, costs associated with these conditions, and statistical analysis of data on participation in and the results of health and wellness promotion programs.

Supplemental files to the report include a PowerPoint of the final briefing on the research and the Executive Summary .

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Continuing to enhance the quality of case study methodology in health services research

Shannon l. sibbald.

1 Faculty of Health Sciences, Western University, London, Ontario, Canada.

2 Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

3 The Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Stefan Paciocco

Meghan fournie, rachelle van asseldonk, tiffany scurr.

Case study methodology has grown in popularity within Health Services Research (HSR). However, its use and merit as a methodology are frequently criticized due to its flexible approach and inconsistent application. Nevertheless, case study methodology is well suited to HSR because it can track and examine complex relationships, contexts, and systems as they evolve. Applied appropriately, it can help generate information on how multiple forms of knowledge come together to inform decision-making within healthcare contexts. In this article, we aim to demystify case study methodology by outlining its philosophical underpinnings and three foundational approaches. We provide literature-based guidance to decision-makers, policy-makers, and health leaders on how to engage in and critically appraise case study design. We advocate that researchers work in collaboration with health leaders to detail their research process with an aim of strengthening the validity and integrity of case study for its continued and advanced use in HSR.

Introduction

The popularity of case study research methodology in Health Services Research (HSR) has grown over the past 40 years. 1 This may be attributed to a shift towards the use of implementation research and a newfound appreciation of contextual factors affecting the uptake of evidence-based interventions within diverse settings. 2 Incorporating context-specific information on the delivery and implementation of programs can increase the likelihood of success. 3 , 4 Case study methodology is particularly well suited for implementation research in health services because it can provide insight into the nuances of diverse contexts. 5 , 6 In 1999, Yin 7 published a paper on how to enhance the quality of case study in HSR, which was foundational for the emergence of case study in this field. Yin 7 maintains case study is an appropriate methodology in HSR because health systems are constantly evolving, and the multiple affiliations and diverse motivations are difficult to track and understand with traditional linear methodologies.

Despite its increased popularity, there is debate whether a case study is a methodology (ie, a principle or process that guides research) or a method (ie, a tool to answer research questions). Some criticize case study for its high level of flexibility, perceiving it as less rigorous, and maintain that it generates inadequate results. 8 Others have noted issues with quality and consistency in how case studies are conducted and reported. 9 Reporting is often varied and inconsistent, using a mix of approaches such as case reports, case findings, and/or case study. Authors sometimes use incongruent methods of data collection and analysis or use the case study as a default when other methodologies do not fit. 9 , 10 Despite these criticisms, case study methodology is becoming more common as a viable approach for HSR. 11 An abundance of articles and textbooks are available to guide researchers through case study research, including field-specific resources for business, 12 , 13 nursing, 14 and family medicine. 15 However, there remains confusion and a lack of clarity on the key tenets of case study methodology.

Several common philosophical underpinnings have contributed to the development of case study research 1 which has led to different approaches to planning, data collection, and analysis. This presents challenges in assessing quality and rigour for researchers conducting case studies and stakeholders reading results.

This article discusses the various approaches and philosophical underpinnings to case study methodology. Our goal is to explain it in a way that provides guidance for decision-makers, policy-makers, and health leaders on how to understand, critically appraise, and engage in case study research and design, as such guidance is largely absent in the literature. This article is by no means exhaustive or authoritative. Instead, we aim to provide guidance and encourage dialogue around case study methodology, facilitating critical thinking around the variety of approaches and ways quality and rigour can be bolstered for its use within HSR.

Purpose of case study methodology

Case study methodology is often used to develop an in-depth, holistic understanding of a specific phenomenon within a specified context. 11 It focuses on studying one or multiple cases over time and uses an in-depth analysis of multiple information sources. 16 , 17 It is ideal for situations including, but not limited to, exploring under-researched and real-life phenomena, 18 especially when the contexts are complex and the researcher has little control over the phenomena. 19 , 20 Case studies can be useful when researchers want to understand how interventions are implemented in different contexts, and how context shapes the phenomenon of interest.

In addition to demonstrating coherency with the type of questions case study is suited to answer, there are four key tenets to case study methodologies: (1) be transparent in the paradigmatic and theoretical perspectives influencing study design; (2) clearly define the case and phenomenon of interest; (3) clearly define and justify the type of case study design; and (4) use multiple data collection sources and analysis methods to present the findings in ways that are consistent with the methodology and the study’s paradigmatic base. 9 , 16 The goal is to appropriately match the methods to empirical questions and issues and not to universally advocate any single approach for all problems. 21

Approaches to case study methodology

Three authors propose distinct foundational approaches to case study methodology positioned within different paradigms: Yin, 19 , 22 Stake, 5 , 23 and Merriam 24 , 25 ( Table 1 ). Yin is strongly post-positivist whereas Stake and Merriam are grounded in a constructivist paradigm. Researchers should locate their research within a paradigm that explains the philosophies guiding their research 26 and adhere to the underlying paradigmatic assumptions and key tenets of the appropriate author’s methodology. This will enhance the consistency and coherency of the methods and findings. However, researchers often do not report their paradigmatic position, nor do they adhere to one approach. 9 Although deliberately blending methodologies may be defensible and methodologically appropriate, more often it is done in an ad hoc and haphazard way, without consideration for limitations.

Cross-analysis of three case study approaches, adapted from Yazan 2015

The post-positive paradigm postulates there is one reality that can be objectively described and understood by “bracketing” oneself from the research to remove prejudice or bias. 27 Yin focuses on general explanation and prediction, emphasizing the formulation of propositions, akin to hypothesis testing. This approach is best suited for structured and objective data collection 9 , 11 and is often used for mixed-method studies.

Constructivism assumes that the phenomenon of interest is constructed and influenced by local contexts, including the interaction between researchers, individuals, and their environment. 27 It acknowledges multiple interpretations of reality 24 constructed within the context by the researcher and participants which are unlikely to be replicated, should either change. 5 , 20 Stake and Merriam’s constructivist approaches emphasize a story-like rendering of a problem and an iterative process of constructing the case study. 7 This stance values researcher reflexivity and transparency, 28 acknowledging how researchers’ experiences and disciplinary lenses influence their assumptions and beliefs about the nature of the phenomenon and development of the findings.

Defining a case

A key tenet of case study methodology often underemphasized in literature is the importance of defining the case and phenomenon. Researches should clearly describe the case with sufficient detail to allow readers to fully understand the setting and context and determine applicability. Trying to answer a question that is too broad often leads to an unclear definition of the case and phenomenon. 20 Cases should therefore be bound by time and place to ensure rigor and feasibility. 6

Yin 22 defines a case as “a contemporary phenomenon within its real-life context,” (p13) which may contain a single unit of analysis, including individuals, programs, corporations, or clinics 29 (holistic), or be broken into sub-units of analysis, such as projects, meetings, roles, or locations within the case (embedded). 30 Merriam 24 and Stake 5 similarly define a case as a single unit studied within a bounded system. Stake 5 , 23 suggests bounding cases by contexts and experiences where the phenomenon of interest can be a program, process, or experience. However, the line between the case and phenomenon can become muddy. For guidance, Stake 5 , 23 describes the case as the noun or entity and the phenomenon of interest as the verb, functioning, or activity of the case.

Designing the case study approach

Yin’s approach to a case study is rooted in a formal proposition or theory which guides the case and is used to test the outcome. 1 Stake 5 advocates for a flexible design and explicitly states that data collection and analysis may commence at any point. Merriam’s 24 approach blends both Yin and Stake’s, allowing the necessary flexibility in data collection and analysis to meet the needs.

Yin 30 proposed three types of case study approaches—descriptive, explanatory, and exploratory. Each can be designed around single or multiple cases, creating six basic case study methodologies. Descriptive studies provide a rich description of the phenomenon within its context, which can be helpful in developing theories. To test a theory or determine cause and effect relationships, researchers can use an explanatory design. An exploratory model is typically used in the pilot-test phase to develop propositions (eg, Sibbald et al. 31 used this approach to explore interprofessional network complexity). Despite having distinct characteristics, the boundaries between case study types are flexible with significant overlap. 30 Each has five key components: (1) research question; (2) proposition; (3) unit of analysis; (4) logical linking that connects the theory with proposition; and (5) criteria for analyzing findings.

Contrary to Yin, Stake 5 believes the research process cannot be planned in its entirety because research evolves as it is performed. Consequently, researchers can adjust the design of their methods even after data collection has begun. Stake 5 classifies case studies into three categories: intrinsic, instrumental, and collective/multiple. Intrinsic case studies focus on gaining a better understanding of the case. These are often undertaken when the researcher has an interest in a specific case. Instrumental case study is used when the case itself is not of the utmost importance, and the issue or phenomenon (ie, the research question) being explored becomes the focus instead (eg, Paciocco 32 used an instrumental case study to evaluate the implementation of a chronic disease management program). 5 Collective designs are rooted in an instrumental case study and include multiple cases to gain an in-depth understanding of the complexity and particularity of a phenomenon across diverse contexts. 5 , 23 In collective designs, studying similarities and differences between the cases allows the phenomenon to be understood more intimately (for examples of this in the field, see van Zelm et al. 33 and Burrows et al. 34 In addition, Sibbald et al. 35 present an example where a cross-case analysis method is used to compare instrumental cases).

Merriam’s approach is flexible (similar to Stake) as well as stepwise and linear (similar to Yin). She advocates for conducting a literature review before designing the study to better understand the theoretical underpinnings. 24 , 25 Unlike Stake or Yin, Merriam proposes a step-by-step guide for researchers to design a case study. These steps include performing a literature review, creating a theoretical framework, identifying the problem, creating and refining the research question(s), and selecting a study sample that fits the question(s). 24 , 25 , 36

Data collection and analysis

Using multiple data collection methods is a key characteristic of all case study methodology; it enhances the credibility of the findings by allowing different facets and views of the phenomenon to be explored. 23 Common methods include interviews, focus groups, observation, and document analysis. 5 , 37 By seeking patterns within and across data sources, a thick description of the case can be generated to support a greater understanding and interpretation of the whole phenomenon. 5 , 17 , 20 , 23 This technique is called triangulation and is used to explore cases with greater accuracy. 5 Although Stake 5 maintains case study is most often used in qualitative research, Yin 17 supports a mix of both quantitative and qualitative methods to triangulate data. This deliberate convergence of data sources (or mixed methods) allows researchers to find greater depth in their analysis and develop converging lines of inquiry. For example, case studies evaluating interventions commonly use qualitative interviews to describe the implementation process, barriers, and facilitators paired with a quantitative survey of comparative outcomes and effectiveness. 33 , 38 , 39

Yin 30 describes analysis as dependent on the chosen approach, whether it be (1) deductive and rely on theoretical propositions; (2) inductive and analyze data from the “ground up”; (3) organized to create a case description; or (4) used to examine plausible rival explanations. According to Yin’s 40 approach to descriptive case studies, carefully considering theory development is an important part of study design. “Theory” refers to field-relevant propositions, commonly agreed upon assumptions, or fully developed theories. 40 Stake 5 advocates for using the researcher’s intuition and impression to guide analysis through a categorical aggregation and direct interpretation. Merriam 24 uses six different methods to guide the “process of making meaning” (p178) : (1) ethnographic analysis; (2) narrative analysis; (3) phenomenological analysis; (4) constant comparative method; (5) content analysis; and (6) analytic induction.

Drawing upon a theoretical or conceptual framework to inform analysis improves the quality of case study and avoids the risk of description without meaning. 18 Using Stake’s 5 approach, researchers rely on protocols and previous knowledge to help make sense of new ideas; theory can guide the research and assist researchers in understanding how new information fits into existing knowledge.

Practical applications of case study research

Columbia University has recently demonstrated how case studies can help train future health leaders. 41 Case studies encompass components of systems thinking—considering connections and interactions between components of a system, alongside the implications and consequences of those relationships—to equip health leaders with tools to tackle global health issues. 41 Greenwood 42 evaluated Indigenous peoples’ relationship with the healthcare system in British Columbia and used a case study to challenge and educate health leaders across the country to enhance culturally sensitive health service environments.

An important but often omitted step in case study research is an assessment of quality and rigour. We recommend using a framework or set of criteria to assess the rigour of the qualitative research. Suitable resources include Caelli et al., 43 Houghten et al., 44 Ravenek and Rudman, 45 and Tracy. 46

New directions in case study

Although “pragmatic” case studies (ie, utilizing practical and applicable methods) have existed within psychotherapy for some time, 47 , 48 only recently has the applicability of pragmatism as an underlying paradigmatic perspective been considered in HSR. 49 This is marked by uptake of pragmatism in Randomized Control Trials, recognizing that “gold standard” testing conditions do not reflect the reality of clinical settings 50 , 51 nor do a handful of epistemologically guided methodologies suit every research inquiry.

Pragmatism positions the research question as the basis for methodological choices, rather than a theory or epistemology, allowing researchers to pursue the most practical approach to understanding a problem or discovering an actionable solution. 52 Mixed methods are commonly used to create a deeper understanding of the case through converging qualitative and quantitative data. 52 Pragmatic case study is suited to HSR because its flexibility throughout the research process accommodates complexity, ever-changing systems, and disruptions to research plans. 49 , 50 Much like case study, pragmatism has been criticized for its flexibility and use when other approaches are seemingly ill-fit. 53 , 54 Similarly, authors argue that this results from a lack of investigation and proper application rather than a reflection of validity, legitimizing the need for more exploration and conversation among researchers and practitioners. 55

Although occasionally misunderstood as a less rigourous research methodology, 8 case study research is highly flexible and allows for contextual nuances. 5 , 6 Its use is valuable when the researcher desires a thorough understanding of a phenomenon or case bound by context. 11 If needed, multiple similar cases can be studied simultaneously, or one case within another. 16 , 17 There are currently three main approaches to case study, 5 , 17 , 24 each with their own definitions of a case, ontological and epistemological paradigms, methodologies, and data collection and analysis procedures. 37

Individuals’ experiences within health systems are influenced heavily by contextual factors, participant experience, and intricate relationships between different organizations and actors. 55 Case study research is well suited for HSR because it can track and examine these complex relationships and systems as they evolve over time. 6 , 7 It is important that researchers and health leaders using this methodology understand its key tenets and how to conduct a proper case study. Although there are many examples of case study in action, they are often under-reported and, when reported, not rigorously conducted. 9 Thus, decision-makers and health leaders should use these examples with caution. The proper reporting of case studies is necessary to bolster their credibility in HSR literature and provide readers sufficient information to critically assess the methodology. We also call on health leaders who frequently use case studies 56 – 58 to report them in the primary research literature.

The purpose of this article is to advocate for the continued and advanced use of case study in HSR and to provide literature-based guidance for decision-makers, policy-makers, and health leaders on how to engage in, read, and interpret findings from case study research. As health systems progress and evolve, the application of case study research will continue to increase as researchers and health leaders aim to capture the inherent complexities, nuances, and contextual factors. 7

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Health Case Studies

(29 reviews)

Glynda Rees, British Columbia Institute of Technology

Rob Kruger, British Columbia Institute of Technology

Janet Morrison, British Columbia Institute of Technology

Copyright Year: 2017

Publisher: BCcampus

Language: English

Formats Available

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Learn more about reviews.

Reviewed by Jessica Sellars, Medical assistant office instructor, Blue Mountain Community College on 10/11/23

This is a book of compiled and very well organized patient case studies. The author has broken it up by disease patient was experiencing and even the healthcare roles that took place in this patients care. There is a well thought out direction and... read more

Comprehensiveness rating: 5 see less

This is a book of compiled and very well organized patient case studies. The author has broken it up by disease patient was experiencing and even the healthcare roles that took place in this patients care. There is a well thought out direction and plan. There is an appendix to refer to as well if you are needing to find something specific quickly. I have been looking for something like this to help my students have a base to do their project on. This is the most comprehensive version I have found on the subject.

Content Accuracy rating: 5

This is a book compiled of medical case studies. It is very accurate and can be used to learn from great care and mistakes.

Relevance/Longevity rating: 5

This material is very relevant in this context. It also has plenty of individual case studies to utilize in many ways in all sorts of medical courses. This is a very useful textbook and it will continue to be useful for a very long time as you can still learn from each study even if medicine changes through out the years.

Clarity rating: 5

The author put a lot of thought into the ease of accessibility and reading level of the target audience. There is even a "how to use this resource" section which could be extremely useful to students.

Consistency rating: 5

The text follows a very consistent format throughout the book.

Modularity rating: 5

Each case study is individual broken up and in a group of similar case studies. This makes it extremely easy to utilize.

Organization/Structure/Flow rating: 5

The book is very organized and the appendix is through. It flows seamlessly through each case study.

Interface rating: 5

I had no issues navigating this book, It was clearly labeled and very easy to move around in.

Grammatical Errors rating: 5

I did not catch any grammar errors as I was going through the book

Cultural Relevance rating: 5

This is a challenging question for any medical textbook. It is very culturally relevant to those in medical or medical office degrees.

I have been looking for something like this for years. I am so happy to have finally found it.

Reviewed by Cindy Sun, Assistant Professor, Marshall University on 1/7/23

Interestingly, this is not a case of ‘you get what you pay for’. Instead, not only are the case studies organized in a fashion for ease of use through a detailed table of contents, the authors have included more support for both faculty and... read more

Interestingly, this is not a case of ‘you get what you pay for’. Instead, not only are the case studies organized in a fashion for ease of use through a detailed table of contents, the authors have included more support for both faculty and students. For faculty, the introduction section titled ‘How to use this resource’ and individual notes to educators before each case study contain application tips. An appendix overview lists key elements as issues / concepts, scenario context, and healthcare roles for each case study. For students, learning objectives are presented at the beginning of each case study to provide a framework of expectations.

The content is presented accurately and realistic.

The case studies read similar to ‘A Day In the Life of…’ with detailed intraprofessional communications similar to what would be overheard in patient care areas. The authors present not only the view of the patient care nurse, but also weave interprofessional vantage points through each case study by including patient interaction with individual professionals such as radiology, physician, etc.

In addition to objective assessment findings, the authors integrate standard orders for each diagnosis including medications, treatments, and tests allowing the student to incorporate pathophysiology components to their assessments.

Each case study is arranged in the same framework for consistency and ease of use.

This compilation of eight healthcare case studies focusing on new onset and exacerbation of prevalent diagnoses, such as heart failure, deep vein thrombosis, cancer, and chronic obstructive pulmonary disease advancing to pneumonia.

Each case study has a photo of the ‘patient’. Simple as this may seem, it gives an immediate mental image for the student to focus.

Interface rating: 4

As noted by previous reviewers, most of the links do not connect active web pages. This may be due to the multiple options for accessing this resource (pdf download, pdf electronic, web view, etc.).

Grammatical Errors rating: 4

A minor weakness that faculty will probably need to address prior to use is regarding specific term usages differences between Commonwealth countries and United States, such as lung sound descriptors as ‘quiet’ in place of ‘diminished’ and ‘puffers’ in place of ‘inhalers’.

The authors have provided a multicultural, multigenerational approach in selection of patient characteristics representing a snapshot of today’s patient population. Additionally, one case study focusing on heart failure is about a middle-aged adult, contrasting to the average aged patient the students would normally see during clinical rotations. This option provides opportunities for students to expand their knowledge on risk factors extending beyond age.

This resource is applicable to nursing students learning to care for patients with the specific disease processes presented in each case study or for the leadership students focusing on intraprofessional communication. Educators can assign as a supplement to clinical experiences or as an in-class application of knowledge.

Reviewed by Stephanie Sideras, Assistant Professor, University of Portland on 8/15/22

The eight case studies included in this text addressed high frequency health alterations that all nurses need to be able to manage competently. While diabetes was not highlighted directly, it was included as a potential comorbidity. The five... read more

The eight case studies included in this text addressed high frequency health alterations that all nurses need to be able to manage competently. While diabetes was not highlighted directly, it was included as a potential comorbidity. The five overarching learning objectives pulled from the Institute of Medicine core competencies will clearly resonate with any faculty familiar with Quality and Safety Education for Nurses curriculum.

The presentation of symptoms, treatments and management of the health alterations was accurate. Dialogue between the the interprofessional team was realistic. At times the formatting of lab results was confusing as they reflected reference ranges specific to the Canadian healthcare system but these occurrences were minimal and could be easily adapted.

The focus for learning from these case studies was communication - patient centered communication and interprofessional team communication. Specific details, such as drug dosing, was minimized, which increases longevity and allows for easy individualization of the case data.

While some vocabulary was specific to the Canadian healthcare system, overall the narrative was extremely engaging and easy to follow. Subjective case data from patient or provider were formatted in italics and identified as 'thoughts'. Objective and behavioral case data were smoothly integrated into the narrative.

The consistency of formatting across the eight cases was remarkable. Specific learning objectives are identified for each case and these remain consistent across the range of cases, varying only in the focus for the goals for each different health alterations. Each case begins with presentation of essential patient background and the progress across the trajectory of illness as the patient moves from location to location encountering different healthcare professionals. Many of the characters (the triage nurse in the Emergency Department, the phlebotomist) are consistent across the case situations. These consistencies facilitate both application of a variety of teaching methods and student engagement with the situated learning approach.

Case data is presented by location and begins with the patient's first encounter with the healthcare system. This allows for an examination of how specific trajectories of illness are manifested and how care management needs to be prioritized at different stages. This approach supports discussions of care transitions and the complexity of the associated interprofessional communication.

The text is well organized. The case that has two levels of complexity is clearly identified

The internal links between the table of contents and case specific locations work consistently. In the EPUB and the Digital PDF the external hyperlinks are inconsistently valid.

The grammatical errors were minimal and did not detract from readability

Cultural diversity is present across the cases in factors including race, ethnicity, socioeconomic status, family dynamics and sexual orientation.

The level of detail included in these cases supports a teaching approach to address all three spectrums of learning - knowledge, skills and attitudes - necessary for the development of competent practice. I also appreciate the inclusion of specific assessment instruments that would facilitate a discussion of evidence based practice. I will enjoy using these case to promote clinical reasoning discussions of data that is noticed and interpreted with the resulting prioritizes that are set followed by reflections that result from learner choices.

Reviewed by Chris Roman, Associate Professor, Butler University on 5/19/22

It would be extremely difficult for a book of clinical cases to comprehensively cover all of medicine, and this text does not try. Rather, it provides cases related to common medical problems and introduces them in a way that allows for various... read more

Comprehensiveness rating: 4 see less

It would be extremely difficult for a book of clinical cases to comprehensively cover all of medicine, and this text does not try. Rather, it provides cases related to common medical problems and introduces them in a way that allows for various learning strategies to be employed to leverage the cases for deeper student learning and application.

The narrative form of the cases is less subject to issues of accuracy than a more content-based book would be. That said, the cases are realistic and reasonable, avoiding being too mundane or too extreme.

These cases are narrative and do not include many specific mentions of drugs, dosages, or other aspects of clinical care that may grow/evolve as guidelines change. For this reason, the cases should be “evergreen” and can be modified to suit different types of learners.

Clarity rating: 4

The text is written in very accessible language and avoids heavy use of technical language. Depending on the level of learner, this might even be too simplistic and omit some details that would be needed for physicians, pharmacists, and others to make nuanced care decisions.

The format is very consistent with clear labeling at transition points.

The authors point out in the introductory materials that this text is designed to be used in a modular fashion. Further, they have built in opportunities to customize each cases, such as giving dates of birth at “19xx” to allow for adjustments based on instructional objectives, etc.

The organization is very easy to follow.

I did not identify any issues in navigating the text.

The text contains no grammatical errors, though the language is a little stiff/unrealistic in some cases.

Cases involve patients and members of the care team that are of varying ages, genders, and racial/ethnic backgrounds

Reviewed by Trina Larery, Assistant Professor, Pittsburg State University on 4/5/22

The book covers common scenarios, providing allied health students insight into common health issues. The information in the book is thorough and easily modified if needed to include other scenarios not listed. The material was easy to understand... read more

The book covers common scenarios, providing allied health students insight into common health issues. The information in the book is thorough and easily modified if needed to include other scenarios not listed. The material was easy to understand and apply to the classroom. The E-reader format included hyperlinks that bring the students to subsequent clinical studies.

Content Accuracy rating: 4

The treatments were explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse. The case studies were accurate in explanation. The DVT case study incorrectly identifies the location of the clot in the popliteal artery instead of in the vein.

The content is relevant to a variety of different types of health care providers and due to the general nature of the cases, will remain relevant over time. Updates should be made annually to the hyperlinks and to assure current standard of practice is still being met.

Clear, simple and easy to read.

Consistent with healthcare terminology and framework throughout all eight case studies.

The text is modular. Cases can be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point providing great flexibility. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

The book is well organized, presenting in a logical clear fashion. The appendix allows the student to move about the case study without difficulty.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change based on current guidelines. A few hyperlinks had "page not found".

Few grammatical errors were noted in text.

The case studies include people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. There are roughly 25 broken online links or "pages not found", care needs to be taken to update at least annually and assure links are valid and utilizing the most up to date information.

Reviewed by Benjamin Silverberg, Associate Professor/Clinician, West Virginia University on 3/24/22

The appendix reviews the "key roles" and medical venues found in all 8 cases, but is fairly spartan on medical content. The table of contents at the beginning only lists the cases and locations of care. It can be a little tricky to figure out what... read more

Comprehensiveness rating: 3 see less

The appendix reviews the "key roles" and medical venues found in all 8 cases, but is fairly spartan on medical content. The table of contents at the beginning only lists the cases and locations of care. It can be a little tricky to figure out what is going on where, especially since each case is largely conversation-based. Since this presents 8 cases (really 7 with one being expanded upon), there are many medical topics (and venues) that are not included. It's impossible to include every kind of situation, but I'd love to see inclusion of sexual health, renal pathology, substance abuse, etc.

Though there are differences in how care can be delivered based on personal style, changing guidelines, available supplies, etc, the medical accuracy seems to be high. I did not detect bias or industry influence.

Relevance/Longevity rating: 4

Medications are generally listed as generics, with at least current dosing recommendations. The text gives a picture of what care looks like currently, but will be a little challenging to update based on new guidelines (ie, it can be hard to find the exact page in which a medication is dosed/prescribed). Even if the text were to be a little out of date, an instructor can use that to point out what has changed (and why).

Clear text, usually with definitions of medical slang or higher-tier vocabulary. Minimal jargon and there are instances where the "characters" are sorting out the meaning as well, making it accessible for new learners, too.

Overall, the style is consistent between cases - largely broken up into scenes and driven by conversation rather than descriptions of what is happening.

There are 8 (well, again, 7) cases which can be reviewed in any order. Case #2 builds upon #1, which is intentional and a good idea, though personally I would have preferred one case to have different possible outcomes or even a recurrence of illness. Each scene within a case is reasonably short.

Organization/Structure/Flow rating: 4

These cases are modular and don't really build on concepts throughout. As previously stated, case #2 builds upon #1, but beyond that, there is no progression. (To be sure, the authors suggest using case #1 for newer learners and #2 for more advanced ones.) The text would benefit from thematic grouping, a longer introduction and debriefing for each case (there are learning objectives but no real context in medical education nor questions to reflect on what was just read), and progressively-increasing difficulty in medical complexity, ethics, etc.

I used the PDF version and had no interface issues. There are minimal photographs and charts. Some words are marked in blue but those did not seem to be hyperlinked anywhere.

No noticeable errors in grammar, spelling, or formatting were noted.

I appreciate that some diversity of age and ethnicity were offered, but this could be improved. There were Canadian Indian and First Nations patients, for example, as well as other characters with implied diversity, but there didn't seem to be any mention of gender diverse or non-heterosexual people, or disabilities. The cases tried to paint family scenes (the first patient's dog was fairly prominently mentioned) to humanize them. Including more cases would allow for more opportunities to include sex/gender minorities, (hidden) disabilities, etc.

The text (originally from 2017) could use an update. It could be used in conjunction with other Open Texts, as a compliment to other coursework, or purely by itself. The focus is meant to be on improving communication, but there are only 3 short pages at the beginning of the text considering those issues (which are really just learning objectives). In addition to adding more cases and further diversity, I personally would love to see more discussion before and after the case to guide readers (and/or instructors). I also wonder if some of the ambiguity could be improved by suggesting possible health outcomes - this kind of counterfactual comparison isn't possible in real life and could be really interesting in a text. Addition of comprehension/discussion questions would also be worthwhile.

Reviewed by Danielle Peterson, Assistant Professor, University of Saint Francis on 12/31/21

This text provides readers with 8 case studies which include both chronic and acute healthcare issues. Although not comprehensive in regard to types of healthcare conditions, it provides a thorough look at the communication between healthcare... read more

This text provides readers with 8 case studies which include both chronic and acute healthcare issues. Although not comprehensive in regard to types of healthcare conditions, it provides a thorough look at the communication between healthcare workers in acute hospital settings. The cases are primarily set in the inpatient hospital setting, so the bulk of the clinical information is basic emergency care and inpatient protocol: vitals, breathing, medication management, etc. The text provides a table of contents at opening of the text and a handy appendix at the conclusion of the text that outlines each case’s issue(s), scenario, and healthcare roles. No index or glossary present.

Although easy to update, it should be noted that the cases are taking place in a Canadian healthcare system. Terms may be unfamiliar to some students including “province,” “operating theatre,” “physio/physiotherapy,” and “porter.” Units of measurement used include Celsius and meters. Also, the issue of managed care, health insurance coverage, and length of stay is missing for American students. These are primary issues that dictate much of the healthcare system in the US and a primary job function of social workers, nurse case managers, and medical professionals in general. However, instructors that wish to add this to the case studies could do so easily.

The focus of this text is on healthcare communication which makes it less likely to become obsolete. Much of the clinical information is stable healthcare practice that has been standard of care for quite some time. Nevertheless, given the nature of text, updates would be easy to make. Hyperlinks should be updated to the most relevant and trustworthy sources and checked frequently for effectiveness.

The spacing that was used to note change of speaker made for ease of reading. Although unembellished and plain, I expect students to find this format easy to digest and interesting, especially since the script is appropriately balanced with ‘human’ qualities like the current TV shows and songs, the use of humor, and nonverbal cues.

A welcome characteristic of this text is its consistency. Each case is presented in a similar fashion and the roles of the healthcare team are ‘played’ by the same character in each of the scenarios. This allows students to see how healthcare providers prioritize cases and juggle the needs of multiple patients at once. Across scenarios, there was inconsistency in when clinical terms were hyperlinked.

The text is easily divisible into smaller reading sections. However, since the nature of the text is script-narrative format, if significant reorganization occurs, one will need to make sure that the communication of the script still makes sense.

The text is straightforward and presented in a consistent fashion: learning objectives, case history, a script of what happened before the patient enters the healthcare setting, and a script of what happens once the patient arrives at the healthcare setting. The authors use the term, “ideal interactions,” and I would agree that these cases are in large part, ‘best case scenarios.’ Due to this, the case studies are well organized, clear, logical, and predictable. However, depending on the level of student, instructors may want to introduce complications that are typical in the hospital setting.

The interface is pleasing and straightforward. With exception to the case summary and learning objectives, the cases are in narrative, script format. Each case study supplies a photo of the ‘patient’ and one of the case studies includes a link to a 3-minute video that introduces the reader to the patient/case. One of the highlights of this text is the use of hyperlinks to various clinical practices (ABG, vital signs, transfer of patient). Unfortunately, a majority of the links are broken. However, since this is an open text, instructors can update the links to their preference.

Although not free from grammatical errors, those that were noticed were minimal and did not detract from reading.

Cultural Relevance rating: 4

Cultural diversity is visible throughout the patients used in the case studies and includes factors such as age, race, socioeconomic status, family dynamics, and sexual orientation. A moderate level of diversity is noted in the healthcare team with some stereotypes: social workers being female, doctors primarily male.

As a social work instructor, I was grateful to find a text that incorporates this important healthcare role. I would have liked to have seen more content related to advance directives, mediating decision making between the patient and care team, emotional and practical support related to initial diagnosis and discharge planning, and provision of support to colleagues, all typical roles of a medical social worker. I also found it interesting that even though social work was included in multiple scenarios, the role was only introduced on the learning objectives page for the oncology case.

Reviewed by Crystal Wynn, Associate Professor, Virginia State University on 7/21/21

The text covers a variety of chronic diseases within the cases; however, not all of the common disease states were included within the text. More chronic diseases need to be included such as diabetes, cancer, and renal failure. Not all allied... read more

The text covers a variety of chronic diseases within the cases; however, not all of the common disease states were included within the text. More chronic diseases need to be included such as diabetes, cancer, and renal failure. Not all allied health care team members are represented within the case study. Key terms appear throughout the case study textbook and readers are able to click on a hyperlink which directs them to the definition and an explanation of the key term.

Content is accurate, error-free and unbiased.

The content is up-to-date, but not in a way that will quickly make the text obsolete within a short period of time. The text is written and/or arranged in such a way that necessary updates will be relatively easy and straightforward to implement.

The text is written in lucid, accessible prose, and provides adequate context for any jargon/technical terminology used

The text is internally consistent in terms of terminology and framework.

The text is easily and readily divisible into smaller reading sections that can be assigned at different points within the course. Each case can be divided into a chronic disease state unit, which will allow the reader to focus on one section at a time.

Organization/Structure/Flow rating: 3

The topics in the text are presented in a logical manner. Each case provides an excessive amount of language that provides a description of the case. The cases in this text reads more like a novel versus a clinical textbook. The learning objectives listed within each case should be in the form of questions or activities that could be provided as resources for instructors and teachers.

Interface rating: 3

There are several hyperlinks embedded within the textbook that are not functional.

The text contains no grammatical errors.

Cultural Relevance rating: 3

The text is not culturally insensitive or offensive in any way. More examples of cultural inclusiveness is needed throughout the textbook. The cases should be indicative of individuals from a variety of races and ethnicities.

Reviewed by Rebecca Hillary, Biology Instructor, Portland Community College on 6/15/21

This textbook consists of a collection of clinical case studies that can be applicable to a wide range of learning environments from supplementing an undergraduate Anatomy and Physiology Course, to including as part of a Medical or other health... read more

This textbook consists of a collection of clinical case studies that can be applicable to a wide range of learning environments from supplementing an undergraduate Anatomy and Physiology Course, to including as part of a Medical or other health care program. I read the textbook in E-reader format and this includes hyperlinks that bring the students to subsequent clinical study if the book is being used in a clinical classroom. This book is significantly more comprehensive in its approach from other case studies I have read because it provides a bird’s eye view of the many clinicians, technicians, and hospital staff working with one patient. The book also provides real time measurements for patients that change as they travel throughout the hospital until time of discharge.

Each case gave an accurate sense of the chaos that would be present in an emergency situation and show how the conditions affect the practitioners as well as the patients. The reader gets an accurate big picture--a feel for each practitioner’s point of view as well as the point of view of the patient and the patient’s family as the clock ticks down and the patients are subjected to a number of procedures. The clinical information contained in this textbook is all in hyperlinks containing references to clinical skills open text sources or medical websites. I did find one broken link on an external medical resource.

The diseases presented are relevant and will remain so. Some of the links are directly related to the Canadian Medical system so they may not be applicable to those living in other regions. Clinical links may change over time but the text itself will remain relevant.

Each case study clearly presents clinical data as is it recorded in real time.

Each case study provides the point of view of several practitioners and the patient over several days. While each of the case studies covers different pathology they all follow this same format, several points of view and data points, over a number of days.

The case studies are divided by days and this was easy to navigate as a reader. It would be easy to assign one case study per body system in an Anatomy and Physiology course, or to divide them up into small segments for small in class teaching moments.

The topics are presented in an organized way showing clinical data over time and each case presents a large number of view points. For example, in the first case study, the patient is experiencing difficulty breathing. We follow her through several days from her entrance to the emergency room. We meet her X Ray Technicians, Doctor, Nurses, Medical Assistant, Porter, Physiotherapist, Respiratory therapist, and the Lab Technicians running her tests during her stay. Each practitioner paints the overall clinical picture to the reader.

I found the text easy to navigate. There were not any figures included in the text, only clinical data organized in charts. The figures were all accessible via hyperlink. Some figures within the textbook illustrating patient scans could have been helpful but I did not have trouble navigating the links to visualize the scans.

I did not see any grammatical errors in the text.

The patients in the text are a variety of ages and have a variety of family arrangements but there is not much diversity among the patients. Our seven patients in the eight case studies are mostly white and all cis gendered.

Some of the case studies, for example the heart failure study, show clinical data before and after drug treatments so the students can get a feel for mechanism in physiological action. I also liked that the case studies included diet and lifestyle advice for the patients rather than solely emphasizing these pharmacological interventions. Overall, I enjoyed reading through these case studies and I plan to utilize them in my Anatomy and Physiology courses.

Reviewed by Richard Tarpey, Assistant Professor, Middle Tennessee State University on 5/11/21

As a case study book, there is no index or glossary. However, medical and technical terms provide a useful link to definitions and explanations that will prove useful to students unfamiliar with the terms. The information provided is appropriate... read more

As a case study book, there is no index or glossary. However, medical and technical terms provide a useful link to definitions and explanations that will prove useful to students unfamiliar with the terms. The information provided is appropriate for entry-level health care students. The book includes important health problems, but I would like to see coverage of at least one more chronic/lifestyle issue such as diabetes. The book covers adult issues only.

Content is accurate without bias

The content of the book is relevant and up-to-date. It addresses conditions that are prevalent in today's population among adults. There are no pediatric cases, but this does not significantly detract from the usefulness of the text. The format of the book lends to easy updating of data or information.

The book is written with clarity and is easy to read. The writing style is accessible and technical terminology is explained with links to more information.

Consistency is present. Lack of consistency is typically a problem with case study texts, but this book is consistent with presentation, format, and terminology throughout each of the eight cases.

The book has high modularity. Each of the case studies can be used independently from the others providing flexibility. Additionally, each case study can be partitioned for specific learning objectives based on the learning objectives of the course or module.

The book is well organized, presenting students conceptually with differing patient flow patterns through a hospital. The patient information provided at the beginning of each case is a wonderful mechanism for providing personal context for the students as they consider the issues. Many case studies focus on the problem and the organization without students getting a patient's perspective. The patient perspective is well represented in these cases.

The navigation through the cases is good. There are some terminology and procedure hyperlinks within the cases that do not work when accessed. This is troubling if you intend to use the text for entry-level health care students since many of these links are critical for a full understanding of the case.

There are some non-US variants of spelling and a few grammatical errors, but these do not detract from the content of the messages of each case.

The book is inclusive of differing backgrounds and perspectives. No insensitive or offensive references were found.

I like this text for its application flexibility. The book is useful for non-clinical healthcare management students to introduce various healthcare-related concepts and terminology. The content is also helpful for the identification of healthcare administration managerial issues for students to consider. The book has many applications.

Reviewed by Paula Baldwin, Associate Professor/Communication Studies, Western Oregon University on 5/10/21

The different case studies fall on a range, from crisis care to chronic illness care. read more

The different case studies fall on a range, from crisis care to chronic illness care.

The contents seems to be written as they occurred to represent the most complete picture of each medical event's occurence.

These case studies are from the Canadian medical system, but that does not interfere with it's applicability.

It is written for a medical audience, so the terminology is mostly formal and technical.

Some cases are shorter than others and some go in more depth, but it is not problematic.

The eight separate case studies is the perfect size for a class in the quarter system. You could combine this with other texts, videos or learning modalities, or use it alone.

As this is a case studies book, there is not a need for a logical progression in presentation of topics.

No problems in terms of interface.

I have not seen any grammatical errors.

I did not see anything that was culturally insensitive.

I used this in a Health Communication class and it has been extraordinarily successful. My studies are analyzing the messaging for the good, the bad, and the questionable. The case studies are widely varied and it gives the class insights into hospital experiences, both front and back stage, that they would not normally be able to examine. I believe that because it is based real-life medical incidents, my students are finding the material highly engaging.

Reviewed by Marlena Isaac, Instructor, Aiken Technical College on 4/23/21

This text is great to walk through patient care with entry level healthcare students. The students are able to take in the information, digest it, then provide suggestions to how they would facilitate patient healing. Then when they are faced with... read more

This text is great to walk through patient care with entry level healthcare students. The students are able to take in the information, digest it, then provide suggestions to how they would facilitate patient healing. Then when they are faced with a situation in clinical they are not surprised and now how to move through it effectively.

The case studies provided accurate information that relates to the named disease.

It is relevant to health care studies and the development of critical thinking.

Cases are straightforward with great clinical information.

Clinical information is provided concisely.

Appropriate for clinical case study.

Presented to facilitate information gathering.

Takes a while to navigate in the browser.

Cultural Relevance rating: 1

Text lacks adequate representation of minorities.

Reviewed by Kim Garcia, Lecturer III, University of Texas Rio Grande Valley on 11/16/20

The book has 8 case studies, so obviously does not cover the whole of medicine, but the cases provided are descriptive and well developed. Cases are presented at different levels of difficulty, making the cases appropriate for students at... read more

The book has 8 case studies, so obviously does not cover the whole of medicine, but the cases provided are descriptive and well developed. Cases are presented at different levels of difficulty, making the cases appropriate for students at different levels of clinical knowledge. The human element of both patient and health care provider is well captured. The cases are presented with a focus on interprofessional interaction and collaboration, more so than teaching medical content.

Content is accurate and un-biased. No errors noted. Most diagnostic and treatment information is general so it will remain relevant over time. The content of these cases is more appropriate for teaching interprofessional collaboration and less so for teaching the medical care for each diagnosis.

The content is relevant to a variety of different types of health care providers (nurses, radiologic technicians, medical laboratory personnel, etc) and due to the general nature of the cases, will remain relevant over time.

Easy to read. Clear headings are provided for sections of each case study and these section headings clearly tell when time has passed or setting has changed. Enough description is provided to help set the scene for each part of the case. Much of the text is written in the form of dialogue involving patient, family and health care providers, making it easy to adapt for role play. Medical jargon is limited and links for medical terms are provided to other resources that expound on medical terms used.

The text is consistent in structure of each case. Learning objectives are provided. Cases generally start with the patient at home and move with the patient through admission, testing and treatment, using a variety of healthcare services and encountering a variety of personnel.

The text is modular. Cases could be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

Each case follows a patient in a logical, chronologic fashion. A clear table of contents and appendix are provided which allows the user to quickly locate desired content. It would be helpful if the items in the table of contents and appendix were linked to the corresponding section of the text.

The hyperlinks to content outside this book work, however using the back arrow on your browser returns you to the front page of the book instead of to the point at which you left the text. I would prefer it if the hyperlinks opened in a new window or tab so closing that window or tab would leave you back where you left the text.

No grammatical errors were noted.

The text is culturally inclusive and appropriate. Characters, both patients and care givers are of a variety of races, ethnicities, ages and backgrounds.

I enjoyed reading the cases and reviewing this text. I can think of several ways in which I will use this content.

Reviewed by Raihan Khan, Instructor/Assistant Professor, James Madison University on 11/3/20

The book contains several important health issues, however still missing some chronic health issues that the students should learn before they join the workforce, such as diabetes-related health issues suffered by the patients. read more

The book contains several important health issues, however still missing some chronic health issues that the students should learn before they join the workforce, such as diabetes-related health issues suffered by the patients.

The health information contained in the textbook is mostly accurate.

I think the book is written focusing on the current culture and health issues faced by the patients. To keep the book relevant in the future, the contexts especially the culture/lifestyle/health care modalities, etc. would need to be updated regularly.

The language is pretty simple, clear, and easy to read.

There is no complaint about consistency. One of the main issues of writing a book, consistency was well managed by the authors.

The book is easy to explore based on how easy the setup is. Students can browse to the specific section that they want to read without much hassle of finding the correct information.

The organization is simple but effective. The authors organized the book based on what can happen in a patient's life and what possible scenarios students should learn about the disease. From that perspective, the book does a good job.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change that is beyond the author's control. It's frustrating for the reader when the external link shows no information.

The book is free of any major language and grammatical errors.

The book might do a little better in cultural competency. e.g. Last name Singh is mainly for Sikh people. In the text Harj and Priya Singh are Muslim. the authors can consult colleagues who are more familiar with those cultures and revise some cultural aspects of the cases mentioned in the book.

The book is a nice addition to the open textbook world. Hope to see more health issues covered by the book.

Reviewed by Ryan Sheryl, Assistant Professor, California State University, Dominguez Hills on 7/16/20

This text contains 8 medical case studies that reflect best practices at the time of publication. The text identifies 5 overarching learning objectives: interprofessional collaboration, client centered care, evidence-based practice, quality... read more

This text contains 8 medical case studies that reflect best practices at the time of publication. The text identifies 5 overarching learning objectives: interprofessional collaboration, client centered care, evidence-based practice, quality improvement, and informatics. While the case studies do not cover all medical conditions or bodily systems, the book is thorough in conveying details of various patients and medical team members in a hospital environment. Rather than an index or glossary at the end of the text, it contains links to outside websites for more information on medical tests and terms referenced in the cases.

The content provided is reflective of best practices in patient care, interdisciplinary collaboration, and communication at the time of publication. It is specifically accurate for the context of hospitals in Canada. The links provided throughout the text have the potential to supplement with up-to-date descriptions and definitions, however, many of them are broken (see notes in Interface section).

The content of the case studies reflects the increasingly complex landscape of healthcare, including a variety of conditions, ages, and personal situations of the clients and care providers. The text will require frequent updating due to the rapidly changing landscape of society and best practices in client care. For example, a future version may include inclusive practices with transgender clients, or address ways medical racism implicitly impacts client care (see notes in Cultural Relevance section).

The text is written clearly and presents thorough, realistic details about working and being treated in an acute hospital context.

The text is very straightforward. It is consistent in its structure and flow. It uses consistent terminology and follows a structured framework throughout.

Being a series of 8 separate case studies, this text is easily and readily divisible into smaller sections. The text was designed to be taken apart and used piece by piece in order to serve various learning contexts. The parts of each case study can also be used independently of each other to facilitate problem solving.

The topics in the case studies are presented clearly. The structure of each of the case studies proceeds in a similar fashion. All of the cases are set within the same hospital so the hospital personnel and service providers reappear across the cases, giving a textured portrayal of the experiences of the various service providers. The cases can be used individually, or one service provider can be studied across the various studies.

The text is very straightforward, without complex charts or images that could become distorted. Many of the embedded links are broken and require updating. The links that do work are a very useful way to define and expand upon medical terms used in the case studies.

Grammatical errors are minimal and do not distract from the flow of the text. In one instance the last name Singh is spelled Sing, and one patient named Fred in the text is referred to as Frank in the appendix.

The cases all show examples of health care personnel providing compassionate, client-centered care, and there is no overt discrimination portrayed. Two of the clients are in same-sex marriages and these are shown positively. It is notable, however, that the two cases presenting people of color contain more negative characteristics than the other six cases portraying Caucasian people. The people of color are the only two examples of clients who smoke regularly. In addition, the Indian client drinks and is overweight, while the First Nations client is the only one in the text to have a terminal diagnosis. The Indian client is identified as being Punjabi and attending a mosque, although there are only 2% Muslims in the Punjab province of India. Also, the last name Singh generally indicates a person who is a Hindu or Sikh, not Muslim.

Reviewed by Monica LeJeune, RN Instructor, LSUE on 4/24/20

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process. read more

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process.

Accurately presents health scenarios with real life assessment techniques and patient outcomes.

Relevant to nursing practice.

Clearly written and easily understood.

Consistent with healthcare terminology and framework

Has a good reading flow.

Topics presented in logical fashion

Easy to read.

No grammatical errors noted.

Text is not culturally insensitive or offensive.

Good book to have to teach nursing students.

Reviewed by april jarrell, associate professor, J. Sargeant Reynolds Community College on 1/7/20

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process. read more

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process.

The content is accurate and evidence based. There is no bias noted

The content in the text is relevant, up to date for nursing students. It will be easy to update content as needed because the framework allows for addition to the content.

The text is clear and easy to understand.

Framework and terminology is consistent throughout the text; the case study is a continual and takes the student on a journey with the patient. Great for learning!

The case studies can be easily divided into smaller sections to allow for discussions, and weekly studies.

The text and content progress in a logical, clear fashion allowing for progression of learning.

No interface issues noted with this text.

No grammatical errors noted in the text.

No racial or culture insensitivity were noted in the text.

I would recommend this text be used in nursing schools. The use of case studies are helpful for students to learn and practice the nursing process.

Reviewed by Lisa Underwood, Practical Nursing Instructor, NTCC on 12/3/19

The text provides eight comprehensive case studies that showcase the different viewpoints of the many roles involved in patient care. It encompasses the most common seen diagnoses seen across healthcare today. Each case study comes with its own... read more

The text provides eight comprehensive case studies that showcase the different viewpoints of the many roles involved in patient care. It encompasses the most common seen diagnoses seen across healthcare today. Each case study comes with its own set of learning objectives that can be tweaked to fit several allied health courses. Although the case studies are designed around the Canadian Healthcare System, they are quite easily adaptable to fit most any modern, developed healthcare system.

Content Accuracy rating: 3

Overall, the text is quite accurate. There is one significant error that needs to be addressed. It is located in the DVT case study. In the study, a popliteal artery clot is mislabeled as a DVT. DVTs are located in veins, not in arteries. That said, the case study on the whole is quite good. This case study could be used as a learning tool in the classroom for discussion purposes or as a way to test student understanding of DVTs, on example might be, "Can they spot the error?"

At this time, all of the case studies within the text are current. Healthcare is an ever evolving field that rests on the best evidence based practice. Keeping that in mind, educators can easily adapt the studies as the newest evidence emerges and changes practice in healthcare.

All of the case studies are well written and easy to understand. The text includes several hyperlinks and it also highlights certain medical terminology to prompt readers as a way to enhance their learning experience.

Across the text, the language, style, and format of the case studies are completely consistent.

The text is divided into eight separate case studies. Each case study may be used independently of the others. All case studies are further broken down as the focus patient passes through each aspect of their healthcare system. The text's modularity makes it possible to use a case study as individual work, group projects, class discussions, homework or in a simulation lab.

The case studies and the diagnoses that they cover are presented in such a way that educators and allied health students can easily follow and comprehend.

The book in itself is free of any image distortion and it prints nicely. The text is offered in a variety of digital formats. As noted in the above reviews, some of the hyperlinks have navigational issues. When the reader attempts to access them, a "page not found" message is received.

There were minimal grammatical errors. Some of which may be traced back to the differences in our spelling.

The text is culturally relevant in that it includes patients from many different backgrounds and ethnicities. This allows educators and students to explore cultural relevance and sensitivity needs across all areas in healthcare. I do not believe that the text was in any way insensitive or offensive to the reader.

By using the case studies, it may be possible to have an open dialogue about the differences noted in healthcare systems. Students will have the ability to compare and contrast the Canadian healthcare system with their own. I also firmly believe that by using these case studies, students can improve their critical thinking skills. These case studies help them to "put it all together".

Reviewed by Melanie McGrath, Associate Professor, TRAILS on 11/29/19

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case. read more

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case.

I saw no areas of inaccuracy

As in all healthcare texts, treatments and/or tests will change frequently. However, everything is currently up-to-date thus it should be a good reference for several years.

Each case is written so that any level of healthcare student would understand. Hyperlinks in the text is also very helpful.

All of the cases are written in a similar fashion.

Although not structured as a typical text, each case is easily assigned as a stand-alone.

Each case is organized clearly in an appropriate manner.

I did not see any issues.

I did not see any grammatical errors

The text seemed appropriately inclusive. There are no pediatric cases and no cases of intellectually-impaired patients, but those types of cases introduce more advanced problem-solving which perhaps exceed the scope of the text. May be a good addition to the text.

I found this text to be an excellent resource for healthcare students in a variety of fields. It would be best utilized in inter professional courses to help guide discussion.

Reviewed by Lynne Umbarger, Clinical Assistant Professor, Occupational Therapy, Emory and Henry College on 11/26/19

While the book does not cover every scenario, the ones in the book are quite common and troublesome for inexperienced allied health students. The information in the book is thorough enough, and I have found the cases easy to modify for educational... read more

While the book does not cover every scenario, the ones in the book are quite common and troublesome for inexperienced allied health students. The information in the book is thorough enough, and I have found the cases easy to modify for educational purposes. The material was easily understood by the students but challenging enough for classroom discussion. There are no mentions in the book about occupational therapy, but it is easy enough to add a couple words and make inclusion simple.

Very nice lab values are provided in the case study, making it more realistic for students.

These case studies focus on commonly encountered diagnoses for allied health and nursing students. They are comprehensive, realistic, and easily understood. The only difference is that the hospital in one case allows the patient's dog to visit in the room (highly unusual in US hospitals).

The material is easily understood by allied health students. The cases have links to additional learning materials for concepts that may be less familiar or should be explored further in a particular health field.

The language used in the book is consistent between cases. The framework is the same with each case which makes it easier to locate areas that would be of interest to a particular allied health profession.

The case studies are comprehensive but well-organized. They are short enough to be useful for class discussion or a full-blown assignment. The students seem to understand the material and have not expressed that any concepts or details were missing.

Each case is set up like the other cases. There are learning objectives at the beginning of each case to facilitate using the case, and it is easy enough to pull out material to develop useful activities and assignments.

There is a quick chart in the Appendix to allow the reader to determine the professions involved in each case as well as the pertinent settings and diagnoses for each case study. The contents are easy to access even while reading the book.

As a person who attends carefully to grammar, I found no errors in all of the material I read in this book.

There are a greater number of people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book. With each case, I could easily picture the person in the case. This book appears to be Canadian and more inclusive than most American books.

I was able to use this book the first time I accessed it to develop a classroom activity for first-year occupational therapy students and a more comprehensive activity for second-year students. I really appreciate the links to a multitude of terminology and medical lab values/issues for each case. I will keep using this book.

Reviewed by Cindy Krentz, Assistant Professor, Metropolitan State University of Denver on 6/15/19

The book covers eight case studies of common inpatient or emergency department scenarios. I appreciated that they had written out the learning objectives. I liked that the patient was described before the case was started, giving some... read more

The book covers eight case studies of common inpatient or emergency department scenarios. I appreciated that they had written out the learning objectives. I liked that the patient was described before the case was started, giving some understanding of the patient's background. I think it could benefit from having a glossary. I liked how the authors included the vital signs in an easily readable bar. I would have liked to see the labs also highlighted like this. I also felt that it would have been good written in a 'what would you do next?' type of case study.

The book is very accurate in language, what tests would be prudent to run and in the day in the life of the hospital in all cases. One inaccuracy is that the authors called a popliteal artery clot a DVT. The rest of the DVT case study was great, though, but the one mistake should be changed.

The book is up to date for now, but as tests become obsolete and new equipment is routinely used, the book ( like any other health textbook) will need to be updated. It would be easy to change, however. All that would have to happen is that the authors go in and change out the test to whatever newer, evidence-based test is being utilized.

The text is written clearly and easy to understand from a student's perspective. There is not too much technical jargon, and it is pretty universal when used- for example DVT for Deep Vein Thrombosis.

The book is consistent in language and how it is broken down into case studies. The same format is used for highlighting vital signs throughout the different case studies. It's great that the reader does not have to read the book in a linear fashion. Each case study can be read without needing to read the others.

The text is broken down into eight case studies, and within the case studies is broken down into days. It is consistent and shows how the patient can pass through the different hospital departments (from the ER to the unit, to surgery, to home) in a realistic manner. The instructor could use one or more of the case studies as (s)he sees fit.

The topics are eight different case studies- and are presented very clearly and organized well. Each one is broken down into how the patient goes through the system. The text is easy to follow and logical.

The interface has some problems with the highlighted blue links. Some of them did not work and I got a 'page not found' message. That can be frustrating for the reader. I'm wondering if a glossary could be utilized (instead of the links) to explain what some of these links are supposed to explain.

I found two or three typos, I don't think they were grammatical errors. In one case I think the Canadian spelling and the United States spelling of the word are just different.

This is a very culturally competent book. In today's world, however, one more type of background that would merit delving into is the trans-gender, GLBTQI person. I was glad that there were no stereotypes.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. Since we are becoming more interprofessional, I liked that we saw what the phlebotomist and other ancillary personnel (mostly different technicians) did. I think that it could become even more interdisciplinary so colleges and universities could have more interprofessional education- courses or simulations- with the addition of the nurse using social work, nutrition, or other professional health care majors.

Reviewed by Catherine J. Grott, Interim Director, Health Administration Program, TRAILS on 5/5/19

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this. read more

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this.

The book is accurate, however it has numerous broken online links.

Relevance/Longevity rating: 3

The content is very relevant, but some links are out-dated. For example, WHO Guidelines for Safe Surgery 2009 (p. 186) should be updated.

The book is written in clear and concise language. The side stories about the healthcare workers make the text interesting.

The book is consistent in terms of terminology and framework. Some terms that are emphasized in one case study are not emphasized (with online links) in the other case studies. All of the case studies should have the same words linked to online definitions.

Modularity rating: 3

The book can easily be parsed out if necessary. However, the way the case studies have been written, it's evident that different authors contributed singularly to each case study.

The organization and flow are good.

Interface rating: 1

There are numerous broken online links and "pages not found."

The grammar and punctuation are correct. There are two errors detected: p. 120 a space between the word "heart" and the comma; also a period is needed after Dr (p. 113).

I'm not quite sure that the social worker (p. 119) should comment that the patient and partner are "very normal people."

There are roughly 25 broken online links or "pages not found." The BC & Canadian Guidelines (p. 198) could also include a link to US guidelines to make the text more universal . The basilar crackles (p. 166) is very good. Text could be used compare US and Canadian healthcare. Text could be enhanced to teach "soft skills" and interdepartmental communication skills in healthcare.

Reviewed by Lindsey Henry, Practical Nursing Instructor, Fletcher on 5/1/19

I really appreciated how in the introduction, five learning objectives were identified for students. These objectives are paramount in nursing care and they are each spelled out for the learner. Each Case study also has its own learning... read more

I really appreciated how in the introduction, five learning objectives were identified for students. These objectives are paramount in nursing care and they are each spelled out for the learner. Each Case study also has its own learning objectives, which were effectively met in the readings.

As a seasoned nurse, I believe that the content regarding pathophysiology and treatments used in the case studies were accurate. I really appreciated how many of the treatments were also explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse.

The case studies are up to date and correlate with the current time period. They are easily understood.

I really loved how several important medical terms, including specific treatments were highlighted to alert the reader. Many interventions performed were also explained further, which is great to enhance learning for the nursing student or novice nurse. Also, with each scenario, a background and history of the patient is depicted, as well as the perspectives of the patient, patients family member, and the primary nurse. This really helps to give the reader a full picture of the day in the life of a nurse or a patient, and also better facilitates the learning process of the reader.

These case studies are consistent. They begin with report, the patient background or updates on subsequent days, and follow the patients all the way through discharge. Once again, I really appreciate how this book describes most if not all aspects of patient care on a day to day basis.

Each case study is separated into days. While they can be divided to be assigned at different points within the course, they also build on each other. They show trends in vital signs, what happens when a patient deteriorates, what happens when they get better and go home. Showing the entire process from ER admit to discharge is really helpful to enhance the students learning experience.

The topics are all presented very similarly and very clearly. The way that the scenarios are explained could even be understood by a non-nursing student as well. The case studies are very clear and very thorough.

The book is very easy to navigate, prints well on paper, and is not distorted or confusing.

I did not see any grammatical errors.

Each case study involves a different type of patient. These differences include race, gender, sexual orientation and medical backgrounds. I do not feel the text was offensive to the reader.

I teach practical nursing students and after reading this book, I am looking forward to implementing it in my classroom. Great read for nursing students!

Reviewed by Leah Jolly, Instructor, Clinical Coordinator, Oregon Institute of Technology on 4/10/19

Good variety of cases and pathologies covered. read more

Good variety of cases and pathologies covered.

Content Accuracy rating: 2

Some examples and scenarios are not completely accurate. For example in the DVT case, the sonographer found thrombus in the "popliteal artery", which according to the book indicated presence of DVT. However in DVT, thrombus is located in the vein, not the artery. The patient would also have much different symptoms if located in the artery. Perhaps some of these inaccuracies are just typos, but in real-life situations this simple mistake can make a world of difference in the patient's course of treatment and outcomes.

Good examples of interprofessional collaboration. If only it worked this way on an every day basis!

Clear and easy to read for those with knowledge of medical terminology.

Good consistency overall.

Broken up well.

Topics are clear and logical.

Would be nice to simply click through to the next page, rather than going through the table of contents each time.

Minor typos/grammatical errors.

No offensive or insensitive materials observed.

Reviewed by Alex Sargsyan, Doctor of Nursing Practice/Assistant Professor , East Tennessee State University on 10/8/18

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study. read more

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study.

Overall the book is accurately depicting the clinical environment. There are numerous references to external sites. While most of them are correct, some of them are not working. For example Homan’s test link is not working "404 error"

Book is relevant in its current version and can be used in undergraduate and graduate classes. That said, the longevity of the book may be limited because of the character of the clinical education. Clinical guidelines change constantly and it may require a major update of the content.

Cases are written very clearly and have realistic description of an inpatient setting.

The book is easy to read and consistent in the language in all eight cases.

The cases are very well written. Each case is subdivided into logical segments. The segments reflect different setting where the patient is being seen. There is a flow and transition between the settings.

Book has eight distinct cases. This is a great format for a book that presents distinct clinical issues. This will allow the students to have immersive experiences and gain better understanding of the healthcare environment.

Book is offered in many different formats. Besides the issues with the links mentioned above, overall navigation of the book content is very smooth.

Book is very well written and has no grammatical errors.

Book is culturally relevant. Patients in the case studies come different cultures and represent diverse ethnicities.

Reviewed by Justin Berry, Physical Therapist Assistant Program Director, Northland Community and Technical College, East Grand Forks, MN on 8/2/18

This text provides eight patient case studies from a variety of diagnoses, which can be utilized by healthcare students from multiple disciplines. The cases are comprehensive and can be helpful for students to determine professional roles,... read more

This text provides eight patient case studies from a variety of diagnoses, which can be utilized by healthcare students from multiple disciplines. The cases are comprehensive and can be helpful for students to determine professional roles, interprofessional roles, when to initiate communication with other healthcare practitioners due to a change in patient status, and treatment ideas. Some additional patient information, such as lab values, would have been beneficial to include.

Case study information is accurate and unbiased.

Content is up to date. The case studies are written in a way so that they will not be obsolete soon, even with changes in healthcare.

The case studies are well written, and can be utilized for a variety of classroom assignments, discussions, and projects. Some additional lab value information for each patient would have been a nice addition.

The case studies are consistently organized to make it easy for the reader to determine the framework.

The text is broken up into eight different case studies for various patient diagnoses. This design makes it highly modular, and would be easy to assign at different points of a course.

The flow of the topics are presented consistently in a logical manner. Each case study follows a patient chronologically, making it easy to determine changes in patient status and treatment options.

The text is free of interface issues, with no distortion of images or charts.

The text is not culturally insensitive or offensive in any way. Patients are represented from a variety of races, ethnicities, and backgrounds

This book would be a good addition for many different health programs.

Reviewed by Ann Bell-Pfeifer, Instructor/Program Director, Minnesota State Community and Technical College on 5/21/18

The book gives a comprehensive overview of many types of cases for patient conditions. Emergency Room patients may arrive with COPD, heart failure, sepsis, pneumonia, or as motor vehicle accident victims. It is directed towards nurses, medical... read more

The book gives a comprehensive overview of many types of cases for patient conditions. Emergency Room patients may arrive with COPD, heart failure, sepsis, pneumonia, or as motor vehicle accident victims. It is directed towards nurses, medical laboratory technologists, medical radiology technologists, and respiratory therapists and their roles in caring for patients. Most of the overview is accurate. One suggestion is to provide an embedded radiologist interpretation of the exams which are performed which lead to the patients diagnosis.

Overall the book is accurate. Would like to see updates related to the addition of direct radiography technology which is commonly used in the hospital setting.

Many aspects of medicine will remain constant. The case studies seem fairly accurate and may be relevant for up to 3 years. Since technology changes so quickly in medicine, the CT and x-ray components may need minor updates within a few years.

The book clarity is excellent.

The case stories are consistent with each scenario. It is easy to follow the structure and learn from the content.

The book is quite modular. It is easy to break it up into cases and utilize them individually and sequentially.

The cases are listed by disease process and follow a logical flow through each condition. They are easy to follow as they have the same format from the beginning to the end of each case.

The interface seems seamless. Hyperlinks are inserted which provide descriptions and references to medical procedures and in depth definitions.

The book is free of most grammatical errors. There is a place where a few words do not fit the sentence structure and could be a typo.

The book included all types of relationships and ethnic backgrounds. One type which could be added is a transgender patient.

I think the book was quite useful for a variety of health care professionals. The authors did an excellent job of integrating patient cases which could be applied to the health care setting. The stories seemed real and relevant. This book could be used to teach health care professionals about integrated care within the emergency department.

Reviewed by Shelley Wolfe, Assistant Professor, Winona State University on 5/21/18

This text is comprised of comprehensive, detailed case studies that provide the reader with multiple character views throughout a patient’s encounter with the health care system. The Table of Contents accurately reflected the content. It should... read more

This text is comprised of comprehensive, detailed case studies that provide the reader with multiple character views throughout a patient’s encounter with the health care system. The Table of Contents accurately reflected the content. It should be noted that the authors include a statement that conveys that this text is not like traditional textbooks and is not meant to be read in a linear fashion. This allows the educator more flexibility to use the text as a supplement to enhance learning opportunities.

The content of the text appears accurate and unbiased. The “five overarching learning objectives” provide a clear aim of the text and the educator is able to glean how these objectives are captured into each of the case studies. While written for the Canadian healthcare system, this text is easily adaptable to the American healthcare system.

Overall, the content is up-to-date and the case studies provide a variety of uses that promote longevity of the text. However, not all of the blue font links (if using the digital PDF version) were still in working order. I encountered links that led to error pages or outdated “page not found” websites. While the links can be helpful, continued maintenance of these links could prove time-consuming.

I found the text easy to read and understand. I enjoyed that the viewpoints of all the different roles (patient, nurse, lab personnel, etc.) were articulated well and allowed the reader to connect and gain appreciation of the entire healthcare team. Medical jargon was noted to be appropriate for the intended audience of this text.

The terminology and organization of this text is consistent.

The text is divided into 8 case studies that follow a similar organizational structure. The case studies can further be divided to focus on individual learning objectives. For example, the case studies could be looked at as a whole for discussing communication or could be broken down into segments to focus on disease risk factors.

The case studies in this text follow a similar organizational structure and are consistent in their presentation. The flow of individual case studies is excellent and sets the reader on a clear path. As noted previously, this text is not meant to be read in a linear fashion.

This text is available in many different forms. I chose to review the text in the digital PDF version in order to use the embedded links. I did not encounter significant interface issues and did not find any images or features that would distract or confuse a reader.

No significant grammatical errors were noted.

The case studies in this text included patients and healthcare workers from a variety of backgrounds. Educators and students will benefit from expanding the case studies to include discussions and other learning opportunities to help develop culturally-sensitive healthcare providers.

I found the case studies to be very detailed, yet written in a way in which they could be used in various manners. The authors note a variety of ways in which the case studies could be employed with students; however, I feel the authors could also include that the case studies could be used as a basis for simulated clinical experiences. The case studies in this text would be an excellent tool for developing interprofessional communication and collaboration skills in a variety healthcare students.

Reviewed by Darline Foltz, Assistant Professor, University of Cincinnati - Clermont College on 3/27/18

This book covers all areas listed in the Table of Contents. In addition to the detailed patient case studies, there is a helpful section of "How to Use this Resource". I would like to note that this resource "aligns with the open textbooks... read more

This book covers all areas listed in the Table of Contents. In addition to the detailed patient case studies, there is a helpful section of "How to Use this Resource". I would like to note that this resource "aligns with the open textbooks Clinical Procedures for Safer Patient Care and Anatomy and Physiology: OpenStax" as noted by the authors.

The book appears to be accurate. Although one of the learning outcomes is as follows: "Demonstrate an understanding of the Canadian healthcare delivery system.", I did not find anything that is ONLY specific to the Canadian healthcare delivery system other than some of the terminology, i.e. "porter" instead of "transporter" and a few french words. I found this to make the book more interesting for students rather than deter from it. These are patient case studies that are relevant in any country.

The content is up-to-date. Changes in medical science may occur, i.e. a different test, to treat a diagnosis that is included in one or more of the case studies, however, it would be easy and straightforward to implement these changes.

This book is written in lucid, accessible prose. The technical/medical terminology that is used is appropriate for medical and allied health professionals. Something that would improve this text would to provide a glossary of terms for the terms in blue font.

This book is consistent with current medical terminology

This text is easily divided into each of the 6 case studies. The case studies can be used singly according to the body system being addressed or studied.

Because this text is a collection of case studies, flow doesn't pertain, however the organization and structure of the case studies are excellent as they are clear and easy to read.

There are no distractions in this text that would distract or confuse the reader.

I did not identify any grammatical errors.

This text is not culturally insensitive or offensive in any way and uses patients and healthcare workers that are of a variety of races, ethnicities and backgrounds.

I believe that this text would not only be useful to students enrolled in healthcare professions involved in direct patient care but would also be useful to students in supporting healthcare disciplines such as health information technology and management, medical billing and coding, etc.

Table of Contents

• Introduction

Case Study #1: Chronic Obstructive Pulmonary Disease (COPD)

• Learning Objectives
• Patient: Erin Johns
• Emergency Room

Case Study #2: Pneumonia

• Day 0: Emergency Room
• Day 1: Emergency Room
• Day 1: Medical Ward
• Day 2: Medical Ward
• Day 3: Medical Ward
• Day 4: Medical Ward

Case Study #3: Unstable Angina (UA)

• Patient: Harj Singh

Case Study #4: Heart Failure (HF)

• Patient: Meryl Smith
• In the Supermarket
• Day 0: Medical Ward

Case Study #5: Motor Vehicle Collision (MVC)

• Patient: Aaron Knoll
• Crash Scene
• Operating Room
• Post Anaesthesia Care Unit (PACU)
• Surgical Ward

Case Study #6: Sepsis

• Patient: George Thomas
• Sleepy Hollow Care Facility

Case Study #7: Colon Cancer

• Patient: Fred Johnson
• Two Months Ago
• Pre-Surgery Admission

Case Study #8: Deep Vein Thrombosis (DVT)

• Patient: Jamie Douglas

Appendix: Overview About the Authors

Ancillary Material

About the book.

Health Case Studies is composed of eight separate health case studies. Each case study includes the patient narrative or story that models the best practice (at the time of publishing) in healthcare settings. Associated with each case is a set of specific learning objectives to support learning and facilitate educational strategies and evaluation.

The case studies can be used online in a learning management system, in a classroom discussion, in a printed course pack or as part of a textbook created by the instructor. This flexibility is intentional and allows the educator to choose how best to convey the concepts presented in each case to the learner.

Because these case studies were primarily developed for an electronic healthcare system, they are based predominantly in an acute healthcare setting. Educators can augment each case study to include primary healthcare settings, outpatient clinics, assisted living environments, and other contexts as relevant.

About the Contributors

Glynda Rees teaches at the British Columbia Institute of Technology (BCIT) in Vancouver, British Columbia. She completed her MSN at the University of British Columbia with a focus on education and health informatics, and her BSN at the University of Cape Town in South Africa. Glynda has many years of national and international clinical experience in critical care units in South Africa, the UK, and the USA. Her teaching background has focused on clinical education, problem-based learning, clinical techniques, and pharmacology.

Glynda‘s interests include the integration of health informatics in undergraduate education, open accessible education, and the impact of educational technologies on nursing students’ clinical judgment and decision making at the point of care to improve patient safety and quality of care.

Faculty member in the critical care nursing program at the British Columbia Institute of Technology (BCIT) since 2003, Rob has been a critical care nurse for over 25 years with 17 years practicing in a quaternary care intensive care unit. Rob is an experienced educator and supports student learning in the classroom, online, and in clinical areas. Rob’s Master of Education from Simon Fraser University is in educational technology and learning design. He is passionate about using technology to support learning for both faculty and students.

Part of Rob’s faculty position is dedicated to providing high fidelity simulation support for BCIT’s nursing specialties program along with championing innovative teaching and best practices for educational technology. He has championed the use of digital publishing and was the tech lead for Critical Care Nursing’s iPad Project which resulted in over 40 multi-touch interactive textbooks being created using Apple and other technologies.

Rob has successfully completed a number of specialist certifications in computer and network technologies. In 2015, he was awarded Apple Distinguished Educator for his innovation and passionate use of technology to support learning. In the past five years, he has presented and published abstracts on virtual simulation, high fidelity simulation, creating engaging classroom environments, and what the future holds for healthcare and education.

Janet Morrison is the Program Head of Occupational Health Nursing at the British Columbia Institute of Technology (BCIT) in Burnaby, British Columbia. She completed a PhD at Simon Fraser University, Faculty of Communication, Art and Technology, with a focus on health information technology. Her dissertation examined the effects of telehealth implementation in an occupational health nursing service. She has an MA in Adult Education from St. Francis Xavier University and an MA in Library and Information Studies from the University of British Columbia.

Janet’s research interests concern the intended and unintended impacts of health information technologies on healthcare students, faculty, and the healthcare workforce.

She is currently working with BCIT colleagues to study how an educational clinical information system can foster healthcare students’ perceptions of interprofessional roles.

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Welcome To Open Case Studies

Connecting you with real-world public health data.

The Open Case Studies project showcases the possibilities of what can be achieved when working with real-world data.

Housed in a freely accessible GitHub repository, the project’s self-contained and experiential guides demonstrate the data analysis process and the use of various data science methods, tools, and software in the context of messy, real-world data.

These case studies will empower current and future data scientists to leverage real-world data to solve leading public health challenges.

Who Are Open Case Studies For?

Your experiential guide to the power of data analysis.

The Open Case Studies project provides insights about gathering and working with data for students, instructors, and those with experience in data science or statistical methods at nonprofit organizations and public sector agencies.

Each case study in the project focuses on an important public health topic and introduces methods to provide users with the skills and knowledge for greater legibility, reproducibility, rigor, and flexibility in their own data analyses.

Case Study Bank Overview

Real data on ten public health challenges in the U.S.

The following in-depth case studies use real data and focus on five areas of public health that are particularly pressing in the United States.

Vaping Behaviors in American Youth

This case study explores the trends of tobacco product usage among American youths surveyed in the National Youth Tobacco Survey (NYTS) from 2015-2019. It demonstrates how to use survey data and code books and provides an introduction to writing functions to wrangle similar but slightly different data repetitively. The case study introduces packages for using survey weighting and survey design to perform an analysis to compare vaping product usage among different groups, and covers how to use a logistic regression to compare groups for a variable that is binary (such as true or false — in this case it was using vaping products or not). This case study also covers how to make visualizations of multiple groups over time with confidence interval error bars.

Opioids in the United States

This case study examines the number of opioid pills (specifically oxycodone and hydrocodone, as they are the top two misused opioids) shipped to pharmacies and practitioners at the county-level around the United States from 2006 to 2014 using data from the Drug Enforcement Administration (DEA). This case study demonstrates how to get data from a source called an application programming interface (API). It explores why and how to normalize data, as well as why and how to potentially stratify or redefine groups. It also shows how to compare two independent groups when the data is not normally distributed using a test called the Wilcoxon rank sum test (also called the Mann Whitney U test) and how to add confidence intervals to plots (using a method called bootstrapping).

Disparities in Youth Disconnection

This case study focuses on rates of youth (people between 16-24) disconnection (those who are neither working nor in school) among different racial, ethnic and gender subgroups to identify subgroups that may be particularly vulnerable. It demonstrates that deeper inspection of subgroups yields some differences that are not otherwise discernable, how to import data from a PDF using screenshots of sections of the PDF, and how to use the Mann-Kendall trend test to test for the presence of a consistent direction in the relationship of disconnection rates with time. This case study also shows how to make a visualization that stylistically matches that of an existing report, how to add images to plots, and how to create effective bar plots for multiple comparisons across several groups.

Mental Health of American Youth

This case study investigates how the rate of self-reported symptoms of major depressive episodes (MDE) has changed over time among American youth (age 12-17) from 2004-2018. It describes the impact of self-reporting bias in surveys, how to get data directly from a website, as well as how to compare changes in the frequency of a variable between two groups using a chi-squared test to determine if two variables are independent (in this case if the sex of the students influenced the frequency of reported MDE symptoms in 2004 and 2018). This case study also demonstrates how to create direct labels on visualizations with many groups across time, as well as how to create an animated gif.

Exploring CO2 Emissions Across Time

This case study investigates how CO2 emissions have changed since the 1700s and how the level of emissions has compared for different countries around the world. It explores how yearly average temperature and the number of natural disasters in the United States has changed over time and provides an introduction for examining if two sets of data are correlated with one another. This case study also goes into great detail about how to make what are called heatmaps and other plots to visualize multiple groups over time. This includes adding labels directly to lines on plots with multiple lines.

Predicting Annual Air Pollution

This case study uses machine learning methods to predict annual air pollution levels spatially within the United States based on data about population density, urbanization, road density, as well as satellite pollution data and chemical modeling data among other predictors. Machine learning methods are used to predict air pollution levels when traditional monitoring systems are not available in a particular area or when there is not enough spatial granularity with current monitoring systems. The case study also demonstrates how to visualize data using maps.

Exploring Global Patterns of Obesity Across Rural and Urban Regions

This case study compares average Body Mass Index measurements for males and females from rural and urban regions from over 200 countries around the world, with a particular emphasis on the United States. It provides a thorough introduction to wrangling data from a PDF, how to compare two paired groups using the t test and the nonparametric Wilcoxon signed-rank test using R programming, and how to make visualizations of group comparisons that emphasize a particular subset of the data.

Exploring Global Patterns of Dietary Behaviors Associated with Health Risk

This case study investigates the consumption of dietary factors associated with health risk among males and females from over 200 countries around the world, with a particular emphasis on the United States. It demonstrates how to wrangle data from a PDF; how to combine data from two different sources; how to compare two paired groups and multiple paired groups using t-tests, ANOVA, and linear regression; and how to create visualizations of several groups and how to combine plots together with very different scales.

Influence of Multicollinearity on Measured Impact of Right-To-Carry Gun Laws

This case study focuses on two well-known studies that evaluated the influence of right-to-carry gun laws on violent crime rates. It demonstrates a phenomenon called multicollinearity, where explanatory variables that can predict one another can lead to aberrant and unstable findings; how to make visualizations with labels, such as arrows or equations; and how to combine multiple plots together.

School Shootings in the United States

This case study illustrates ways to communicate trends in a dataset about the number and characteristics of school shooting events for students in grades K-12 in the United States since 1970. It demonstrates how to create a dashboard, which is a website that shows patterns in a dataset in a concise manner; how to import data from a Google Sheets document; how to create interactive tables and maps; and how to properly calculate percentages for data when there are missing values.

Which Case Study Is Right For Me?

Connecting with the public health data you need.

The Open Case Studies project approaches data in many different ways. The guide below will help connect you with a case study:

Data science projects often start with a question. Here, you may look for case studies that explore a question that is similar to one you are interested in investigating with your data.

How does something change over time?

Investigating how a variable has changed over time can help identify consistent trends.

How do survey responses compare for different groups over time?

Survey data requires special care and attention to the survey design.

How do groups compare?

Public health researchers are often interested to know if one group is more vulnerable than another or if two or more groups are actually different from one another.

How do groups compare over time?

Comparing several groups over time can provide insight into if the change over time is different for different groups.

How do paired groups compare?

Paired groups are those that are not independent in some way. Perhaps you want to know how data from the same person over time compares with that of another person over time, or perhaps you are interested in how something changed in a city before and after an intervention, or perhaps you want to compare groups using data that has structure where there is coupling or matching of data values across samples.

Are certain groups or possibly subgroups more vulnerable?

Understand how to compare subpopulations at a deeper level.

How does something compare across regions?

Often it is useful to investigate if data differs by region, as many environmental, cultural, and political differences can influence public health outcomes.

How can I predict outcomes for new data?

Learn how the data might look next year or for locations that you don’t have data about.

Does this influence my data?

Analyze how a variable influences another variable.

Are these two variables related to one another?

Understand how two variables are related and how strongly they are related to one another.

How can I display this data for others to find and interpret and use easily?

Make it easy for others to find your data, see the major trends in your data, or search for specific values in your data.

Data can come from many different sources, from the more obvious like an excel file to the less obvious like an image or a website. These case studies demonstrate how to use data from a variety of possible sources.

Using data from a PDF or just parts of a PDF can be challenging. You could type the data into a new excel file, but this can result in mistakes and it is difficult to reproduce.

Data are often in CSV files and it is typically easy to import data and work with data in this form. However, sometimes it can be difficult if, for example, the first few lines are structured differently or if you have unusual missing value indicators.

If you find data on a website that doesn’t allow you to download in a convenient way, you can actually directly import the data into R programming language.

This is one of the most common data forms, and it is typically easy to import data and work with data in this form. However, sometimes it can be challenging, especially if you have many files.

You can extract text from image files. This can be useful if, for example, you want to only use certain parts of a PDF.

It is possible to find the data that you need to use from an application programming interface (API).

Google Sheet

You can download data from a Google Sheet, copy and paste it into Excel, or directly import the data into R programming language.

Survey data/Code books

Working with survey data requires special care and attention, and you can do this directly with R programming language.

Multiple files

If you find that you need to import data from multiple files, there is a more efficient way to do so without importing each one by one.

Data wrangling is the process of organizing your data in a more useful format. These case studies explore how to clean, rearrange, reshape, modify, filter, combine, or join your data.

Extracting data from a PDF

Extracting and organizing data from a PDF will make it easier to use.

Geocoding data

The process of assigning relevant latitude and longitude coordinates to data values is called geocoding. This can be helpful (although not always necessary) to create a map of your data.

Recoding data

If you have data values that are confusing and could be changed to something better, or if you want to convert your data to true or false, you might want to consider recoding these values.

Methods of joining data

Sometimes, you obtain data from multiple sources that need to be combined together.

Filtering data

Perhaps you need to filter your data for only specific values for given variables. In other words, you might want to filter census employment data to only values for females who are also Black and live in Connecticut.

Modifying data (normalizing, transforming, scaling etc.)

Sometimes it is difficult to know when or how to normalize data.

Working with text

You can work with, remove, replace, or change words, phrases, letters, numbers, or punctuation marks in your data.

Reshaping data

Sometimes it is useful to shape your data so that you have many columns (for example, when performing certain analyses), however it can be useful at other times (for example, when creating plots) to collapse multiple columns into fewer columns with more rows.

Repetitive process

Sometimes you need to wrangle multiple datasets from different sources in a similar manner.

A picture is worth a thousand words, particularly when it comes to interpreting data. These case studies demonstrate how to make effective visualizations in various contexts. The first ten represent basic visualizations while 11-22 are more advanced.

A table that is easy to interpret

Adding colors or simple graphics can make tables easier to interpret.

Scatter plot

Scatter plots can be a strong option for evaluating the relationship between variables, and especially for evaluating changes in a variable over time.

Line plots are often useful for evaluating changes over time.

Bar plots are a good choice if you want to compare data to a threshold.

Box plots are particularly useful for comparing groups with many data values. They provide information about the spread of the data.

Pie chart/waffle plot

Pie charts or waffle plots can be a strong option when comparing relative percentages.

It can be difficult to visualize multiple groups at simultaneously. In these situations, heat maps can be a great option.

Correlation plots

If you have many variables and need to know if they are correlated to one another, there are methods to efficiently check this.

Visualize missing data

It can be helpful to quickly identify how much of your data is missing (has NA values).

Create a map of your data

Often the best way to interpret regional differences in data is to make a map.

• Advanced Visualizations

Matching a style

If you are working with collaborators, you can make your visualizations match the style of their figures.

Faceted plots allow you to quickly create multiple plots at once

It can be difficult to visualize multiple groups at the same time, so faceted plots are a great option in this situation.

Adding labels directly to plots with many different groups

If you compare many groups over time, for example, it can be difficult to see which line corresponds to which group. Adding labels directly to these lines can be very helpful and negates the need for an overcomplicated legend.

Emphasize a particular group

Sometimes you will have several different groups and you want to highlight a specific group.

Adding annotations to plots

Adding labels, such as thresholds, arrows, or equations, can make it easier for people to interpret your plot.

Add error bars to your plot

Adding error bars can help convey information about the confidence of the estimates in your plots.

Combine multiple plots together

Sometimes it is useful to put a variety of plots together and add text to explain what the plot shows.

Create an interactive plot when you have too many groups to label

If you compare a very large number of groups, it can be difficult to tell what is happening. Often it can help to make the plot interactive so that the user can hover over points or lines to see what they indicate.

Create an interactive map of your data

Sometimes it is easiest to see regional differences by interacting with and exploring an interactive map.

Create an interactive table of your data

Sometimes you might want to be able to search through your data or allow others to easily do so.

Add images to your figures

Including images to a plot, such as a logo, can be a helpful addition.

Create an interactive dashboard/website for your data

Dashboards can quickly convey major trends in a dataset, and they can also allow users to interact with the data to choose what aspects about the data they wish to explore.

To better understand data, it is helpful to use statistical tests. These case studies demonstrate a variety of statistical tests and concepts.

Are two groups different?

Correlation

Are two variables related to one another?

Are multiple groups different?

Linear regression

Would you like to compare groups?

Chi-squared test of independence

Do the frequencies of two groups suggest that they are independent?

Mann-Kendall Trend test

Is there a consistent change over time?

Machine learning

Would you like to predict data?

Calculate percentages with missing data?

Would you like to calculate percentages, but you are missing some data?

About The Project

Learn about the team behind the Open Case Studies project.

As part of the larger Open Case Studies project (OCS) at opencasestudies.org , these case studies were developed for and funded by the Bloomberg American Health Initiative. The OCS project is made up of a team of researchers at the Johns Hopkins Bloomberg School of Public Health (JHSPH).

Let us know how the Open Case Studies project has enhanced your educational curriculum or ability to tackle tough data-rich research projects.

JHSPH Faculty Contributors

Jessica Fanzo, PhD

Brendan Saloner, PhD

Megan Latshaw, PhD, MHS

Renee M. Johnson, PhD, MPH

Daniel Webster, ScD, MPH

Elizabeth Stuart, PhD

Bloomberg American Health Initiative

Joshua M. Sharfstein, MD – Director, Bloomberg American Health Initiative

Michelle Spencer, MS – Associate Director, Bloomberg American Health Initiative

Paulani Mui, MPH – Special Projects Officer, Bloomberg American Health Initiative

Other Contributors

Aboozar Hadavand, PhD, MA, MS, Minerva University

Roger Peng, PhD, MS, Johns Hopkins Bloomberg School of Public Health

Kirsten Koehler, PhD, MS, Johns Hopkins Bloomberg School of Public Health

Alex McCourt, PhD, JD, MPH, Johns Hopkins Bloomberg School of Public Health

Ashkan Afshin, MD, ScD, MPH, MSc, University of Washington and Institute for Health Metrics and Evaluation (IHME)

Erin Mullany, BA, Institute for Health Metrics and Evaluation (IHME)

External Review Panel

Leslie Myint, PhD, Macalester College

Shannon E. Ellis, PhD, University of California – San Diego

Christina Knudson, PhD, University of St. Thomas

Michael Love, PhD, University of North Carolina

Nicholas Horton, ScD, Amherst College

Mine Çetinkaya-Rundel, PhD, University of Edinburgh, Duke University, RStudio

Let Us Know How You're Using Open Case Studies

As the Open Case Studies project expands, we learn from you. Tell us what data you'd like to see, how you're using the data, or anything we can do to improve the project.

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Case studies.

The Center’s research identifies and explores best practices, which in turn are the foundation for policies, programs, and practices that are implemented by organizations seeking to improve worker health, safety, and well-being. Our case studies provide concise summaries of organizational change implemented using a Total Worker Health ® integrated approach, and are based on the Center’s previous and current research projects.

The Workplace Organizational Health Study The Workplace Organizational Health Study sought to improve the health, safety, and well-being of front-line food service workers by identifying working conditions that could be modified to reduce pain and injuries and improve worker well-being. This case study, developed by the Center, summarizes the implementation of the 2+2 Feedback and Coaching tool, previously used with managers and modified for use with employees. Download the case study

Dartmouth-Hitchcock Medical Center To address rising employee health care expenses, Dartmouth-Hitchcock Medical Center (DHMC) launched an initiative to achieve its vision of the healthiest possible workforce, the foundation of which is an organizational culture that advances employee health, safety, and well-being. This case study, developed by the Center in collaboration with HealthPartners, summarizes the DHMC successful Total Worker Health approach and the resulting beneficial outcomes. Download the case study

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Development of a National Public Health Accreditation Program: A Case Study in Strategic Change Management and Sustainability

Bender, Kaye PHD, RN, FAAN; Beitsch, Leslie MD, JD; Kronstadt, Jessica MPP

Public Health Accreditation Board, Alexandria, Virginia (Dr Bender and Ms Kronstadt); and Florida State University, Tallahassee, Florida (Dr Beitsch).

Correspondence: Kaye Bender, PHD, RN, FAAN, Public Health Accreditation Board, 1600 Duke St, Ste 200, Alexandria, VA 22314 ( [email protected] ).

The authors thank Georges Benjamin, executive director, American Public Health Association; George Hardy, former executive director, Association of State and Territorial Health Officials; Pat Libbey, former executive director, National Association of County and City Health Officials; Grace Gorenflo, public health consultant; Pamela Russo, Robert Wood Johnson Foundation; Liza Corso, Centers for Disease Control and Prevention; Paul Halverson, founding dean, Richard M. Fairbanks School of Public Health, Indiana; Bobby Pestronk, former executive director, National Association of County and City Health Officials; Paul Jarris, former executive director, Association of State and Territorial Health Officials; Hugh Tilson, Professor, UNC School of Public Health and Member, Institute of Medicine. We also acknowledge Records of Ed Thompson, Former State Health Officer, MS Department of Health and Former Deputy Director at the Centers for Disease Control and Prevention, and Records of Marie Fallon, Former Executive Director of the National Association of Local Boards of Health.The information contained in this article reflects the opinions of the authors and does not represent official PHAB board policy. The authors declare no conflicts of interest.

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Business of Well-being

The employee wellness case studies that will inspire you.

In today's fast-paced corporate world, employee wellness has become an essential focus for organizations looking to enhance productivity, improve employee satisfaction, and reduce healthcare costs. Companies across industries are implementing innovative wellness programs and initiatives to promote the well-being of their employees. In this article, we will delve into inspiring case studies that demonstrate the transformative power of employee wellness programs. These success stories highlight the positive impact such initiatives can have on individuals and organizations alike.

Case Study 1: TechCo's Holistic Wellness Approach ‍ TechCo, a leading technology company, recognized the importance of addressing the physical, mental, and emotional well-being of their employees. They implemented a holistic wellness program that encompassed various aspects of well-being. The program included regular exercise classes such as yoga, Pilates, and cardio workouts, along with workshops on mindfulness and stress reduction techniques. TechCo also provided access to mental health resources, including counseling services and meditation apps. Through this comprehensive approach, TechCo witnessed a notable reduction in employee absenteeism and improved overall engagement. The company also experienced an increase in employee retention, as staff members felt supported and valued by the organization.

Case Study 2: PharmaCorp's Health Challenge ‍ PharmaCorp, a pharmaceutical company, aimed to cultivate a culture of health and wellness among their employees. They introduced a company-wide health challenge that encouraged employees to engage in healthy activities and lifestyle choices. The challenge included friendly competitions, rewards, and recognition for participants. Employees were encouraged to track their progress using fitness trackers and wellness apps. Additionally, PharmaCorp organized health and wellness fairs where employees could access health screenings, nutritional counseling, and fitness assessments. As a result, PharmaCorp observed a significant improvement in employees' overall health metrics, including reduced body mass index, decreased cholesterol levels, and increased energy levels. Moreover, the challenge fostered a sense of camaraderie and team spirit among employees, promoting a positive work environment.

Case Study 3: FinServe's Financial Wellness Program ‍ FinServe, a financial services firm, recognized that financial stress can have a significant impact on employee well-being and productivity. To address this, they launched a comprehensive financial wellness program. The initiative included educational workshops on budgeting, retirement planning, and debt management. Additionally, FinServe partnered with financial advisors to offer one-on-one consultations for employees seeking personalized guidance. The program not only alleviated financial stress for employees but also enhanced their overall financial literacy. Employees gained a better understanding of managing their finances effectively, leading to reduced financial anxiety, improved job satisfaction, and increased productivity.

Case Study 4: RetailCo's Work-Life Balance Initiative ‍ RetailCo, a large retail chain, acknowledged the significance of work-life balance in employee well-being. They implemented flexible work arrangements to support their staff members' personal responsibilities and interests. This included remote work options, flexible hours, and compressed workweeks. RetailCo also encouraged employees to take regular breaks and provided opportunities for personal development and wellness activities during working hours. By prioritizing work-life balance, RetailCo saw a substantial decrease in employee burnout and an increase in job satisfaction. Employees reported improved mental health and enhanced productivity, resulting in a positive impact on the company's bottom line.

Case Study 5: ManufacturingCo's Healthy Cafeteria Initiative ‍ ManufacturingCo, a large manufacturing company, decided to promote healthy eating habits among their employees by revamping their cafeteria offerings. They partnered with nutritionists and chefs to create nutritious, delicious, and diverse meal options that catered to different dietary needs. The company introduced clear nutritional labeling for menu items, highlighting the nutritional content and allergen information. Additionally, ManufacturingCo provided nutrition education sessions and cooking workshops to empower employees to make healthier choices both in the cafeteria and at home. This initiative had a profound impact on ManufacturingCo's employees. By providing healthier food options, the company witnessed a positive shift in employees' eating habits and overall well-being. Employees reported feeling more energized and focused throughout the workday, resulting in increased productivity. Moreover, the company saw a decrease in absenteeism and a reduction in healthcare costs associated with diet-related illnesses. ManufacturingCo's commitment to promoting healthy eating not only improved the well-being of their employees but also fostered a culture of wellness within the organization.

Case Study 6: Consulting Firm's Mental Health Support Program ‍ A consulting firm recognized the importance of addressing mental health in the workplace and implemented a comprehensive mental health support program. The program included regular mental health awareness campaigns, training sessions for managers on recognizing and addressing mental health concerns, and confidential counseling services for employees. The consulting firm created a supportive environment where employees felt comfortable seeking help for mental health challenges without fear of judgment or repercussions. As a result, employees reported improved mental well-being, reduced stress levels, and increased job satisfaction. The firm also noticed a decline in mental health-related absenteeism and an improvement in overall team collaboration and productivity.

Case Study 7: Hospitality Company's Wellness Rewards Program ‍ A hospitality company sought to motivate and engage employees in their wellness journey by implementing a rewards program. The program encouraged employees to participate in various wellness activities, such as fitness challenges, health screenings, and stress management workshops. Employees earned points for their participation and were eligible for rewards and incentives based on their accumulated points. This approach not only incentivized employees to prioritize their well-being but also created a sense of friendly competition and camaraderie among the workforce. The company witnessed a significant increase in employee engagement, improved morale, and a decrease in lifestyle-related health issues.

Case Study 8: Education Institution's Employee Development and Wellness Integration ‍ An educational institution recognized the interconnectedness between employee development and wellness. They integrated wellness initiatives into their employee development programs to support the holistic growth of their staff members. The institution offered opportunities for professional development, skill-building workshops, and wellness activities such as yoga classes, meditation sessions, and mindfulness training. By fostering a culture that prioritized both professional growth and personal well-being, the institution experienced higher employee satisfaction, increased retention rates, and a positive impact on student outcomes.

These case studies exemplify the power of employee wellness programs in enhancing the well-being and productivity of individuals within organizations. From holistic wellness approaches and health challenges to financial wellness programs and work-life balance initiatives, these success stories demonstrate the transformative impact that investing in employee well-being can have.

By implementing wellness programs tailored to the unique needs of their workforce, organizations can create a positive work environment, boost employee engagement and satisfaction, and reduce healthcare costs. If you are seeking guidance on implementing or enhancing your organization's wellness program, Global Healthcare Resources offers comprehensive wellness consulting services. Their team of experts can assist you in developing customized strategies and initiatives that align with your company's goals and values.

Embrace the power of employee wellness and unlock the potential for a healthier, happier, and more productive workforce. To learn more about how Global Healthcare Resources can support your wellness journey, visit https://www.globalhealthcareresources.com/wellnessconsulting .

Remember, investing in your employees' well-being is an investment in the success and longevity of your organization. Start prioritizing employee wellness today and witness the positive impact it can have on your workforce and overall business performance.

To explore Global Healthcare Resources' wellness consulting services and discover how they can assist your organization in implementing an effective wellness program, visit https://www.globalhealthcareresources.com/wellnessconsulting .

Top Wellness Leader, Jesse Gavin Shares Deep Insights into Corporate Wellness Transformation for Leaders

Changing the narrative in corporate wellness, an interview with ccws graduate, renee fortuna, human connection is key to a thriving workplace - interview with shelly bell, well-being means different things to everyone - says jessica domann, well-being programs are not a one-size-fits-all solution - csilla lorincz, ccws graduate, featured reading, global healthcare accreditation (gha) launches gha for business and issues organizational resiliency guidelines amidst omicron and emerging variants, how fertility benefits can support your diversity & inclusion efforts, “they dumped us like trash:” creating the worst corporate culture like better.com.

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• 30 May 2024
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Racial Bias Might Be Infecting Patient Portals. Can AI Help?

Doctors and patients turned to virtual communication when the pandemic made in-person appointments risky. But research by Ariel Stern and Mitchell Tang finds that providers' responses can vary depending on a patient's race. Could technology bring more equity to portals?

• 21 May 2024
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The Importance of Trust for Managing through a Crisis

In March 2020, Twiddy & Company, a family-owned vacation rental company known for hospitality rooted in personal interactions, needed to adjust to contactless, remote customer service. With the upcoming vacation season thrown into chaos, President Clark Twiddy had a responsibility to the company’s network of homeowners who rented their homes through the company, to guests who had booked vacations, and to employees who had been recruited by Twiddy’s reputation for treating staff well. Who, if anyone, could he afford to make whole and keep happy? Harvard Business School professor Sandra Sucher, author of the book The Power of Trust: How Companies Build It, Lose It, Regain It, discusses how Twiddy leaned into trust to weather the COVID-19 pandemic in her case, “Twiddy & Company: Trust in a Chaotic Environment.”

• 09 Feb 2024

Slim Chance: Drugs Will Reshape the Weight Loss Industry, But Habit Change Might Be Elusive

Medications such as Ozempic, Wegovy, and Mounjaro have upended a $76 billion industry that has long touted lifestyle shifts as a means to weight loss. Regina Herzlinger says these drugs might bring fast change, especially for busy professionals, but many questions remain unanswered.

• 19 Dec 2023

$15 Billion in Five Years: What Data Tells Us About MacKenzie Scott’s Philanthropy

Scott's hands-off approach and unparalleled pace—helping almost 2,000 organizations and counting—has upended the status quo in philanthropy. While her donations might seem scattershot, an analysis of five years of data by Matthew Lee, Brian Trelstad, and Ethan Tran highlights clear trends and an emerging strategy.

• 09 Nov 2023

What Will It Take to Confront the Invisible Mental Health Crisis in Business?

The pressure to do more, to be more, is fueling its own silent epidemic. Lauren Cohen discusses the common misperceptions that get in the way of supporting employees' well-being, drawing on case studies about people who have been deeply affected by mental illness.

• 03 Oct 2023
• Research Event

Build the Life You Want: Arthur Brooks and Oprah Winfrey Share Happiness Tips

"Happiness is not a destination. It's a direction." In this video, Arthur C. Brooks and Oprah Winfrey reflect on mistakes, emotions, and contentment, sharing lessons from their new book.

• 12 Sep 2023

Can Remote Surgeries Digitally Transform Operating Rooms?

Launched in 2016, Proximie was a platform that enabled clinicians, proctors, and medical device company personnel to be virtually present in operating rooms, where they would use mixed reality and digital audio and visual tools to communicate with, mentor, assist, and observe those performing medical procedures. The goal was to improve patient outcomes. The company had grown quickly, and its technology had been used in tens of thousands of procedures in more than 50 countries and 500 hospitals. It had raised close to $50 million in equity financing and was now entering strategic partnerships to broaden its reach. Nadine Hachach-Haram, founder and CEO of Proximie, aspired for Proximie to become a platform that powered every operating room in the world, but she had to carefully consider the company’s partnership and data strategies in order to scale. What approach would position the company best for the next stage of growth? Harvard Business School associate professor Ariel Stern discusses creating value in health care through a digital transformation of operating rooms in her case, “Proximie: Using XR Technology to Create Borderless Operating Rooms.”

• 28 Aug 2023

How Workplace Wellness Programs Can Give Employees the Energy Boost They Need

At a time when many workers are struggling with mental health issues, workplace wellness programs need to go beyond providing gym discounts and start offering employees tailored solutions that improve their physical and emotional well-being, says Hise Gibson.

• 01 Aug 2023

Can Business Transform Primary Health Care Across Africa?

mPharma, headquartered in Ghana, is trying to create the largest pan-African health care company. Their mission is to provide primary care and a reliable and fairly priced supply of drugs in the nine African countries where they operate. Co-founder and CEO Gregory Rockson needs to decide which component of strategy to prioritize in the next three years. His options include launching a telemedicine program, expanding his pharmacies across the continent, and creating a new payment program to cover the cost of common medications. Rockson cares deeply about health equity, but his venture capital-financed company also must be profitable. Which option should he focus on expanding? Harvard Business School Professor Regina Herzlinger and case protagonist Gregory Rockson discuss the important role business plays in improving health care in the case, “mPharma: Scaling Access to Affordable Primary Care in Africa.”

• 25 Jul 2023

Could a Business Model Help Big Pharma Save Lives and Profit?

Gilead Sciences used a novel approach to help Egypt address a public health crisis while sustaining profits from a key product. V. Kasturi Rangan and participants at a recent seminar hosted by the Institute for the Study of Business in Global Society discussed what it would take to apply the model more widely.

• 23 Jun 2023

This Company Lets Employees Take Charge—Even with Life and Death Decisions

Dutch home health care organization Buurtzorg avoids middle management positions and instead empowers its nurses to care for patients as they see fit. Tatiana Sandino and Ethan Bernstein explore how removing organizational layers and allowing employees to make decisions can boost performance.

• 09 May 2023

Can Robin Williams’ Son Help Other Families Heal Addiction and Depression?

Zak Pym Williams, son of comedian and actor Robin Williams, had seen how mental health challenges, such as addiction and depression, had affected past generations of his family. Williams was diagnosed with generalized anxiety disorder, depression, and post-traumatic stress disorder (PTSD) as a young adult and he wanted to break the cycle for his children. Although his children were still quite young, he began considering proactive strategies that could help his family’s mental health, and he wanted to share that knowledge with other families. But how can Williams help people actually take advantage of those mental health strategies and services? Professor Lauren Cohen discusses his case, “Weapons of Self Destruction: Zak Pym Williams and the Cultivation of Mental Wellness.”

• 26 Apr 2023

How Martine Rothblatt Started a Company to Save Her Daughter

When serial entrepreneur Martine Rothblatt (founder of Sirius XM) received her seven-year-old daughter’s diagnosis of Pulmonary Arterial Hypertension (PAH), she created United Therapeutics and developed a drug to save her life. When her daughter later needed a lung transplant, Rothblatt decided to take what she saw as the logical next step: manufacturing organs for transplantation. Rothblatt’s entrepreneurial career exemplifies a larger debate around the role of the firm in creating solutions for society’s problems. If companies are uniquely good at innovating, what voice should society have in governing the new technologies that firms create? Harvard Business School professor Debora Spar debates these questions in the case “Martine Rothblatt and United Therapeutics: A Series of Implausible Dreams.” As part of a new first-year MBA course at Harvard Business School, this case examines the central question: what is the social purpose of the firm?

• 25 Apr 2023

Using Design Thinking to Invent a Low-Cost Prosthesis for Land Mine Victims

Bhagwan Mahaveer Viklang Sahayata Samiti (BMVSS) is an Indian nonprofit famous for creating low-cost prosthetics, like the Jaipur Foot and the Stanford-Jaipur Knee. Known for its patient-centric culture and its focus on innovation, BMVSS has assisted more than one million people, including many land mine survivors. How can founder D.R. Mehta devise a strategy that will ensure the financial sustainability of BMVSS while sustaining its human impact well into the future? Harvard Business School Dean Srikant Datar discusses the importance of design thinking in ensuring a culture of innovation in his case, “BMVSS: Changing Lives, One Jaipur Limb at a Time.”

• 31 Mar 2023

Can a ‘Basic Bundle’ of Health Insurance Cure Coverage Gaps and Spur Innovation?

One in 10 people in America lack health insurance, resulting in $40 billion of care that goes unpaid each year. Amitabh Chandra and colleagues say ensuring basic coverage for all residents, as other wealthy nations do, could address the most acute needs and unlock efficiency.

• 13 Mar 2023

The Power of Personal Connections: How Shared Experiences Boost Performance

Doctors who train together go on to provide better patient care later in their careers. What could teams in other industries learn? Research by Maximilian Pany and J. Michael McWilliams.

• 14 Feb 2023

When a Vacation Isn’t Enough, a Sabbatical Can Recharge Your Life—and Your Career

Burning out and ready to quit? Consider an extended break instead. Drawing from research inspired by his own 900-mile journey, DJ DiDonna offers practical advice to help people chart a new path through a sabbatical.

• 10 Feb 2023

COVID-19 Lessons: Social Media Can Nudge More People to Get Vaccinated

Social networks have been criticized for spreading COVID-19 misinformation, but the platforms have also helped public health agencies spread the word on vaccines, says research by Michael Luca and colleagues. What does this mean for the next pandemic?

• 12 Dec 2022

Buy-In from Black Patients Suffers When Drug Trials Don’t Include Them

Diversifying clinical trials could build trust in new treatments among Black people and their physicians. Research by Joshua Schwartzstein, Marcella Alsan, and colleagues probes the ripple effects of underrepresentation in testing, and offers a call to action for drugmakers.

• 06 Sep 2022

Curbing an Unlikely Culprit of Rising Drug Prices: Pharmaceutical Donations

Policymakers of every leaning have vowed to rein in prescription drug costs, with little success. But research by Leemore Dafny shows how closing a loophole on drugmaker donations could eliminate one driver of rising expenses.

Patient-Centered Case Study for Health and Illness in the Undergraduate Program

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Each group of students will review the assigned case study and prepare a PowerPoint presentation that must include the following: (a) answers and key points, (b) three interactive activities (e.g., NCLEX/NextGen style questions, Games, Video Quizzes, etc.) for the class, and (c) each group member presenting a portion in front of the class. The students will have 15 minutes to present their case study and 5 additional minutes to answer questions. In addition, each student completes a peer evaluation of one presenting group as part of the overall assignment.

The case studies are reviewed each semester by the instructor and adjusted to the concepts being taught in class. Then pre-assigned dates are provided for the case studies so that they are presented the week after the concept has been taught by the professor. The questions within each case study have similar formatting that promotes students using critical thinking and decision-making. Additionally, the students create a patient plan of care through a series of questions and answers without formally writing up a care plan. This allows the students to discuss what they learned with each other, work together as a team, and apply their knowledge. Students also develop three interactive learning activities for their classmates, and present one of the activities, and the other two are used as part of the end-of-the-semester review before the final. This assists in solidifying their knowledge concept while offering another teaching strategy for their peers to learn from. Each student presents their portion of the case study, and every student completes a peer review group or presentation. Each case study is graded using a standardized grading rubric noted within the assessment strategies that ensure all students are addressing the key concepts of the case study.

Download Student Instructions & Case Study

Integrative Learning Strategies

Case study has been used in nursing education to apply nursing knowledge to clinical practice and to promote critical thinking and reasoning (Mauldin, 2021). For this activity, case study exemplars were developed based on nursing textbooks and relevant examples from recent studies in nursing research. Subsequently, they were reviewed by faculty members whose expertise is in nursing education. Case study exemplars reinforce dynamic learning activities where students follow patient problems through the chronology of illness from primary care and chronic conditions to acute and complex health conditions. The case studies also included patients from diverse backgrounds facing health disparities.

Integrative learning strategies involve:

• Flipped classroom
• Formative assessment
• Inclusive teaching pedagogy

Assessment Strategies

Download Rubric

Students are assessed and evaluated on their ability to exhibit critical thinking and clinical judgment on the given case study as it evolves in complexity. There is not necessarily a right or wrong for all the questions, but for the students to demonstrate their thought process, rationale, and understanding of the responses they provide. In addition, their responses are patient-focused, assisting the students in reviewing all possible options and choosing the best one for their patients.

Possible Courses

• Health & Illness Courses
• Medical Surgical Theory Courses
• Clinical Practice Courses
• Acute and Chronic Nursing Care

Additional Resources/Publications

American Nurses Association. Nursing: Scope and Standards of Practice, 4th Edition . 4th ed. American Nurses Association, 2021.

Betty Kehl Richardson. 2007. Case Studies in Psychiatric Nursing . Delmar Pub.

Caputi, Linda. Think Like a Nurse: A Handbook . New York, United States: Macmilla Publishers, 2020.

Giddens, Jean Foret. Concepts for Nursing Practice (with EBook Access on VitalSource ). M Marssen, Netherlands: Elsevier Gezondheidszorg, 2020.

Ignatavicius, Donna Cne D Anef, M PhD Linda Faan Workman, Cherie PhD Mba Coi Rebar, and Nicole Dnp M Coi Heimgartner. Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care . Maarssen, Netherlands: Elsevier Gezondheidszorg, 2020.

Ignatavicius, Donna. Developing Clinical Judgment for Professional Nursing and the Next-Generation NCLEX-RN Examination . Maarssen, Netherlands: Elsevier Gezondheidszorg, 2020.

Mauldin, Betsy. 2021. “Bringing Clinical Context to the Classroom in Nursing Pharmacology.” Nursing Education Perspectives Publish Ahead of Print (December). https://doi.org/10.1097/01.nep.0000000000000919.

Sub-competencies for entry-level professional nursing education:

• 1.2a Apply or employ knowledge from nursing science as well as the natural, physical, and social sciences to build an understanding of the human experience and nursing practice.
• 1.2d Examine influence of personal values in decision making for nursing practice.
• 1.2e Demonstrate ethical decision making.
• 1.3a Demonstrate clinical reasoning.
• 1.3c Incorporate knowledge from nursing and other disciplines to support clinical judgment.
• 2.2b Consider individual beliefs, values, and personalized information in communications.
• 2.2c Use a variety of communication modes appropriate for the context.
• 2.3e Distinguish between normal and abnormal health findings.
• 2.3f Apply nursing knowledge to gain a holistic perspective of the person, family, community, and population.
• 2.3g Communicate findings of a comprehensive assessment.
• 2.4a Synthesize assessment data in the context of the individual’s current preferences, situation, and experience.
• 2.4b Create a list of problems/health concerns.
• 2.4c Prioritize problems/health concerns.
• 2.4d Understand and apply the results of social screening, psychological testing, laboratory data, imaging studies, and other diagnostic tests in actions and plans of care.
• 2.4e Contribute as a team member to the formation and improvement of diagnoses.
• 2.5a Engage the individual and the team in plan development.
• 2.5b Organize care based on mutual health goals.
• 2.5c Prioritize care based on best evidence.
• 2.5d Incorporate evidence-based intervention to improve outcomes and safety.
• 2.5e Anticipate outcomes of care (expected, unexpected, and potentially adverse).
• 2.5f Demonstrate rationale for plan.
• 2.5g Address individuals’ experiences and perspectives in designing plans of care.
• 4.1e Participate in scholarly inquiry as a team member.
• 4.1f Evaluate research.
• 4.1g Communicate scholarly findings.
• 9.2f Apply principles of therapeutic relationships and professional boundaries.
• 9.2g Communicate in a professional manner.
• 9.4b Adhere to the registered nurse scope and standards of practice.

Posted: March 24, 2023

Submitted by:

Nicole Simonson, DNP, RN, University of Wisconsin-Milwaukee, College of Nursing Lisa Brennan DNP, MBA, RN, FNP-BC, University of Wisconsin-Milwaukee, College of Nursing Vipavee Thongpriwan, PhD, RN, CNE, University of Wisconsin-Milwaukee, College of Nursing

Domain 1: Knowledge for Nursing Practice Domain 2: Person-Centered Care Domain 4: Scholarship for Nursing Discipline Domain 9: Professionalism

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Published on 9.7.2024 in Vol 8 (2024)

Evaluation of a Remote Patient Monitoring Program During the COVID-19 Pandemic: Retrospective Case Study With a Mixed Methods Explanatory Sequential Design

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Payment Rates for Medicaid Home- and Community-Based Services: States’ Responses to Workforce Challenges

Alice Burns , Maiss Mohamed , and Molly O’Malley Watts Published: Oct 24, 2023

• Issue Brief
• Appendix Tables

Long-standing workforce challenges in Medicaid home- and community-based services (HCBS) were exacerbated by the pandemic and addressing them is the top priority for most state HCBS programs. New flexibilities combined with funding provided through the American Rescue Plan Act helped states enact new policies to address those issues during the pandemic, but many of those policies are ending and federal funding will expire. This issue brief describes states’ ongoing efforts to respond to the workforce crunch and how they pay HCBS workers, which are central challenges in ensuring that HCBS services are accessible to the 4 million Medicaid enrollees who use them. The data come from the 21 st KFF survey of officials administering Medicaid HCBS programs in all 50 states and the District of Columbia, which states completed between May and August 2023. The survey was sent to each state official responsible for overseeing the administration of HCBS benefits (including home health, personal care, and waiver services for specific populations such as people with physical disabilities). All states except Florida responded to the 2023 survey, but response rates for certain questions were lower. Key takeaways include:

• All responding states (which includes the District of Columbia) reported taking actions to address workforce shortages, including raising payment rates in most states (Figure 1).
• All states reported shortages of HCBS workers, most frequently among direct support professionals, personal care attendants, nursing staff, and home health aides.
• Most (43) states reported permanent closures of HCBS providers within the last year.
• Among the 34 states that reported time-based payment rates for personal care providers, most pay less than $20 per hour.

What are Medicaid HCBS and how are they provided and paid for?

HCBS are one type of long-term services and supports (LTSS), which encompass a broad range of paid and unpaid medical and personal care services. LTSS assist with activities of daily living (such as eating, bathing, and dressing) and instrumental activities of daily living (such as preparing meals, managing medication, and housekeeping). They are provided to people who need such services because of aging, chronic illness, or disability and may be provided in institutional settings such as nursing facilities or in people’s homes and the community. Services provided in non-institutional settings are usually referred to as HCBS and include a wide range of services such as adult daycare, home health, personal care, transportation, and supported employment. A wide variety of workers provide HCBS, and most positions require minimal training and education (see Box 1). In 2020, Medicaid was the primary payer for LTSS, covering over half of all spending in in the U.S.

Box 1: The HCBS Workforce

The HCBS workforce is diverse and encompasses individuals with a variety of job titles. Depending on the state and the specific services offered, the people who provide HCBS include personal care aides, direct support professionals, home health aides, certified nursing assistants, and independent providers. Different types of providers are paid differently and are subject to different training and certification requirements. Home health aides and certified nursing assistants are the only types of providers that must comply with federal training and certification standards.

• Personal care aides assist with the activities of daily living, housekeeping tasks, meal preparation, and medication management.
• Direct support professionals provide a broader range of services than personal care aides such as employment supports.
• Home health aides and certified nursing assistants provide clinical care in community settings and help with the activities of daily living.
• Independent providers are employed directly by the people who are receiving HCBS through what are called “self-directed services.” Some independent providers are family caregivers , who may be paid by the Medicaid program for the services they provide.

People who provide HCBS are nearly all female (85% in 2021) and nonwhite. Most have less than an associate degree and although over half work full time, many receive public assistance such as Medicaid or food and nutrition assistance.

All HCBS are optional except for the mandatory home health benefit, and most benefits—including personal care—first became available through optional Medicaid “waiver” programs. If services are provided through a state plan, they must be offered to all eligible individuals. In contrast, services provided under waivers, such as 1115s or 1915(c)s, may be restricted to specific groups based on geographic region, income, or type of disability. Waivers may also include a wider range of service types than can be provided under state plans. Because all HCBS besides home health were first available through waivers, services were generally tailored to certain types of Medicaid enrollees such as those with intellectual disabilities or those with physical disabilities, and benefit packages were also specific to those groups’ needs. Many HCBS are now available through Medicaid state plans and available to all enrollees in the state. KFF estimates that over 4 million Medicaid enrollees use HCBS, and that the numbers of people using HCBS through the state plan are similar to the numbers using HCBS through waivers.

In KFF’s 2023 survey of state HCBS programs, all states reported offering personal care and other optional HCBS, most commonly through 1915(c) waivers (Figure 2, Appendix Table 2). States are required to offer home health through their Medicaid state plan and 34 states also offer personal care through the state plan. All states also offer HCBS waivers—either an 1115 waiver (14 states with one waiver in each state) and/or a 1915(c) waiver (47 states and 258 waivers total). Most 1915(c) waivers serve specific populations, with 47 states having waivers for people with intellectual or developmental disabilities and 42 states having waivers for people who are ages 65 and older or have physical disabilities. Ohio was the only state to report a new 1915(c) waiver in 2023, serving people under age 21 who have complex behavioral health needs that would require an inpatient level of psychiatric care.

Over half of states use managed care to provide at least some HCBS, particularly for benefits provided through the state plan or 1115 waivers. In managed care, states pay managed care plans a set fee—often called a capitation payment—for each person enrolled and the managed care plans are responsible for providing all services to enrollees. Use of managed care to provide HCBS has been growing over time , with states using managed care to make their Medicaid spending more predictable and to help coordinate the services enrollees use. Among the 14 states with 1115 waivers, 10 use managed care plans to provide at least some of the HCBS and over half of states use managed care plans to provide at least some home health and personal care. Managed care was much less common under the 1915(c) waivers, particularly for waivers serving people with intellectual or developmental disabilities—of the 47 states with such waivers, only 6 provided any of the benefits through managed care.

How are states addressing the workforce challenges in HCBS?

All responding states reported workforce shortages in 2023, with the most common shortages being among direct support professionals (50 states), personal care attendants (49 states), and nursing staff (49 states) (Figure 3, Appendix Table 3). States were asked if they had shortages of each type of provider but were not provided with a definition of shortage. Most states also reported shortages in home health aides (47 states), case managers (45 states), community-based mental health providers (38 states), and occupational, physical, and speech therapy providers (35 states). In some cases, states may not have reported a shortage of a particular type of provider because that type of service is not offered through the HCBS program.

All states but one (Nebraska) reported shortages for more than one type of provider and 48 states reported shortages among five or more provider types. Such shortages may reflect ongoing effects from the pandemic, but also low levels of compensation coupled with increasing requirements of providers. In the summer of 2021, HCBS providers in focus groups reported that their jobs had high physical demands and mental demands that were often “overwhelming.” The groups described their wages as low, particularly given the demands of their jobs; and how staffing shortages made their jobs harder because they may not know if they would be able to leave work at the end of their shift. Similarly, in the 2023 survey, California reported “difficult finding qualified providers due to low Medi-Cal reimbursement rates, losing providers due to Electronic Visit Verification (EVV) requirements, and finding qualified homemaker and attendant care providers post-COVID.” ( Electronic visit verification requires providers to document electronically the services provided, the recipient, the provider, and the time, date, and location of services. The federal requirement took effect in January 2020 for personal care and in January 2023 for home health services.)

Within the last year, 43 states experienced permanent closures of HCBS providers, which were most common among adult day health programs (32 states), group homes (29 states), and assisted living facilities (27 states) (Figure 4, Appendix Table 4). States were asked if there were any permanent closures of providers within each type of setting that provides HCBS. Between 10 and 20 states reported closures of supported employment providers (19 states), providers working in enrollees’ homes (18 states), community mental health providers (14 states), and home health agencies (11 states). Arizona and Tennessee reported that closures were unknown to the state.

Most states reported closures among more than one type of provider: 37 states reported closures among two or more provider types, 23 states reported closures among 4 or more provider types, and 1 state (Maine) reported closures among all eight provider types. Some closures reflect provider shortages: Minnesota reported that “providers have downsized to coordinate locations due to staffing shortages.” On the other hand, some closures reflect the fact that many companies struggled during the pandemic and have not recovered: Louisiana reported that day services were not a feasible business model during the pandemic because of “limited to no attendance.” (Day services, also known as day care, are provided to people in centers rather than in people’s homes. The services are intended to support independence and socialization while also providing family caregivers with a break during the day.)

All responding states reported taking actions to address provider shortages, with 48 states increasing payment rates, 42 states developing or expanding worker education and training programs, and 41 states offering incentive payments to recruit or retain workers (Figure 1, Appendix Table 1). Less common initiatives included establishing or raising the state minimum wage (20 states) and offering paid sick leave for workers (19 states). States also reported several other types of initiatives to strengthen the workforce, including creating platforms or support systems to connect job seekers with employers and positions, launching a social media campaign, and providing outreach to prospective employees.

Some states have permanent payment rate increases in place for providers, but 13 states reported that payment rate increases for at least some of the workers were temporary. Only 14 states have payment formulas that automatically increase with the costs of living, but those formulas do not apply across all types of workers.

How much do states pay for Medicaid HCBS?

KFF asked states to report their average dollar rate per visit paid to two types of HCBS provider agencies (personal care agencies and home health agencies) and three types of specific HCBS providers (personal care providers, home health aides, and registered nurses), but many states were unable to report all rates (Figure 5, Appendix Table 5). The number of states that did not provide payment rates or reported that payment rates were unknown was 8 for personal care agencies and 24 for home health agencies. Even more states did not provide payment rates for specific provider types: For each specific type of provider, nearly half of states did not provide payment rate information or reported that payment rates were unknown.

If provisions of a proposed Biden Administration rule are finalized, states would be required to report such detailed payment rates (see Box 2). If that rule is finalized as proposed, states would be required to report payment rates for certain HCBS and to demonstrate that at least 80% of the payments went to compensation for providers, also described as “direct care workers.” Meeting that requirement would require states to know both agency and provider payment rates. Among the states that were able to report payment rates, only 15 could report payment rates for personal care agencies, home health agencies, personal care providers, and home health aides, all of which would be required under the rule. Those 15 states include states that reported a mix of time-based and visit-based rates, which makes comparisons between provider and agency rates more complicated. Given the challenges for states in collecting such data, federal guidance might be required to achieve consistent reporting across states.

Box 2: Proposed Rule on Access to HCBS

On May 3, 2023, the Biden Administration released a proposed rule aimed at ensuring access to Medicaid services, which has several notable provisions aimed at addressing HCBS workforce challenges. States would be required to report payment rates for personal care, home health aide, and homemaker services to increase transparency around payment rates. For services provided through 1915(c) waivers and through the 1915 state plan authorities, the proposed rule has additional requirements related to the HCBS workforce, including the following.

• The proposed rule would require states to demonstrate that payment rates are “adequate to ensure a sufficient direct care workforce to meet the needs of beneficiaries and provide access to services in the amount, duration, and scope specified in the person-centered plan.”
• The rule would also require states to demonstrate that at least 80 percent of total payments for homemaker services, home health aide services, and personal care services are compensation to direct care workers.
• States would be required to report the number of people on waiting lists for services.
•  States would also have to report the average amount of time from when homemaker services, home health aide services, or personal care services are initially approved to when services begin and the percentage of authorized hours that are provided.

The proposed rule also includes provisions that would strengthen requirements around person-centered planning and needs assessment, create new requirements around incident management, establish requirements for people to file grievances if they are receiving HCBS from the state Medicaid program, and require states to report on nationally-standardized quality measures. Provisions would take effect on a rolling basis, between 2 and 4 years after the rule is finalized.

States reported many reasons why it was difficult to report payment rates, including the following.

• Some states reported that services were bundled together in various ways and therefore, the payment rates were not distinguishable. For example, New Hampshire wrote: “as personal care is not a distinct service, this data cannot be determined.”
• Among states with managed care, some states responded that they did not know the payment rates for agencies because the services were paid for by managed care plans and they did not have access to those payment rates.
• Other states responded that they knew the payment rates for agencies but not what the agencies paid their direct care workers. Multiple states reported that they do not “dictate” what agencies pay to providers or that individual providers negotiate their own payment rates with the agencies.
• Still other states reported that payment rates were too varied across providers and individuals. For example, Indiana reported that payment rates varied from $400 to $6,000 per month: That variation reflected the fact that there are over 400 personal care agencies, and each person has different levels of needs which vary week to week. Hawaii reported that visits vary in terms of what is provided and that the five managed care plans providing HCBS use different methodologies for collecting data, making it impossible to provide “an accurate dollar average.”

In addition to having difficulty reporting payment rates, many states reported different payment rates for personal care across different waivers and the waiver payment rates often differ from the payment rates for personal care provided through the state plan. When states reported multiple payment rates for personal care, KFF used the median of those payment rates in the analysis.

Although KFF asked states to report the average dollar rate per visit, states varied in their reporting of payment rates, with most states reporting payment rates by time (either 15 minutes or one hour), and a smaller number of states reporting rates that were per visit or per day. Most states reported payment rates by time and among those states, payments for personal care workers are generally below $20 per hour. Rates for home health aides are somewhat higher, reflecting the additional training requirements for such workers. Among the states with payment rates in the highest category, some reported that the rates were per visit or per day. Others did not indicate whether their rates were based on time or another basis, but it is likely that most payment rates in the highest category are per visit or per day.

Payment rates to home health agencies are generally larger than those to personal care agencies, but there is considerable variation in both (Figure 6). Across the states, the median hourly payment rates to home health agencies range from $27 to $149 among most states whereas those for personal care agencies range from $10 to $36.

The payment rates to HCBS providers also show considerable variation and are somewhat higher than those reported by other organizations on account of differences in reporting and provider categorization (Figure 6). KFF’s survey estimates that median payment rates to providers are $19 per hour for personal care providers, $28 for home health aides, and $43 for registered nurses. It is difficult to compare those numbers to those of other organizations for the following reasons.

• Other organizations group classes of providers together differently. PHI recently reported that in 2022, home care workers made an average of $14.50 per hour and residential care aides made $15.39 per hour. The Bureau of Labor Statistics reports $14.51 per hour for home health and personal care aides in 2022.
• Other organizations include payment rates for workers regardless of the source of payment whereas KFF rates only reflect the Medicaid rates and Medicaid often covers more intensive personal care services than other payers.

Among states that deliver HCBS through managed care , 20 states reported that the fee-for-service payment rate is the minimum amount MCOs could pay providers. Out of the 36 states that use managed care to provide at least some HCBS, none of the states reported that fee-for-service rates were the maximum amount that managed care plans could pay providers. There were 20 states that reported fee-for-service rates were the minimum payment rates, 13 states that reported there was no relationship between the fee-for-service and managed care rates, and 3 states that reported the answer was unknown or did not respond to the question. Even among states that do not directly tie fee-for-service rates to managed care rates, the fee-for-service rates may affect negotiations between health plans and HCBS providers, thereby, affecting the managed care rates. For example, Texas reported that “the Medicaid fee schedule serves as a primary negotiating tool for both MCOs [managed care plans] and providers in Texas. Many MCO/provider reimbursement contracts are directly tied to the Medicaid FFS [fee-for-service] fee schedule through established percentages (e.g., 100%, 102%, 95%, etc.). Furthermore, it is common for provider reimbursement contracts that are directly tied to the Medicaid fee schedule (i.e., set at a % of Medicaid) to automatically adjust when the Medicaid fee schedule changes.”

What may happen to the Medicaid HCBS workforce in the next few years?

How does the workforce shortage for Medicaid HCBS fit in with the broader staffing challenges for long-term services and supports (LTSS)? Recent analysis on the Peterson-KFF Health System Tracker shows that, as of June 2023, the number of workers in LTSS settings was measurably lower than in early 2020. Shortages and high turnover among LTSS workers reflect demanding working conditions and relatively low wages. The Biden Administration has released a proposed rule that would increase nursing facility staffing levels. KFF analysis shows that fewer than 1 in 5 nursing facilities would currently meet the levels of staffing that have been recommended, and concerns have been raised that there are not enough workers for nursing facilities to hire. Immigrants could help fill some of those positions, but a backlog of green card petitions prompted the State Department to cutoff eligibility for anyone who applied after June 1, 2022. There are concerns that the freeze on green card petitions will further exacerbate nursing shortages across both health and long-term care sectors. These challenges will only grow as the population ages: Arizona estimates that it will need to increase the workforce by over 35,000 positions to meet the demands of a growing population of older adults. Such factors highlight that the workforce crisis in Medicaid HCBS is part of an overall crisis in the LTSS sector.

How will states continue to address workforce challenges in Medicaid HCBS as pandemic-era flexibilities and funding come to an end? Many of the payment rate increases and bonuses for retention and recruitment were funded by extra federal funding available through the American Rescue Plan Act , but as that funding expires, states will have to find alternative funding sources if they want to maintain spending levels. The state of New York reported: “Workforce issues are paramount and the State is making major investments to strengthen the workforce through APRA [American Rescue Plan Act] initiatives.” States also used pandemic-era authorities to expand access to HCBS, in particular, by allowing family caregivers to be paid providers and increasing payment rates. Those authorities will all end by November 11, 2023, and it is unknown whether the expiration of those authorities will increase challenges in accessing Medicaid HCBS.

How will proposed requirements for reporting LTSS payment rates affect states’ payments for Medicaid LTSS? Current proposed rules aim to address workforce shortages in the nursing facility and HCBS sectors by requiring states to report more information about Medicaid payment rates and the percentage of states’ payments that go towards worker compensation. It is unknown how requirements in the final rules will compare with the proposed rules (including the timeline for states to meet the new requirements), and whether reporting requirements will affect the ways in which states pay for LTSS. Both new rules are likely to put upward pressure on payment rates and spending on LTSS but there is no new federal funding for Medicaid’s costs, which are shared between the federal and state governments, so it is unknown where the new funding may come from. Also unknown is whether the need to report payment rates could deter states from pursuing alternative payment approaches such as value-based care or bundled payments, which aim to promote improved health and well-being for people but often obscure payment rates for specific services or providers.

• Home/Community Services
• Health Workforce
• Access to Care
• Long-Term Care
• Nursing Facilities

news release

• In Response to Home-Care Workforce Shortages, Most States Report Increasing Medicaid’s Payment Rates and Expanding Worker Opportunities

Also of Interest

• Pandemic-Era Changes to Medicaid Home- and Community-Based Services (HCBS): A Closer Look at Family Caregiver Policies
• Ending the Public Health Emergency for Medicaid Home- and Community-Based Services
• Ongoing Impacts of the Pandemic on Medicaid Home & Community-Based Services (HCBS) Programs: Findings from a 50-State Survey
• About 1 in 5 Nursing Facilities Would Currently Meet Proposed Requirements for Nursing Staff Hours

• Open access
• Published: 10 July 2024

Development and validity testing of a matrix to evaluate maturity of clinical pathways: a case study in Saskatchewan, Canada

• Crystal Lynn Larson 1 ,
• Jason Robert Vanstone 1 ,
• Taysa-Rhea Mise 1 ,
• Susan Mary Tupper 1 , 2 ,
• Gary Groot 1 , 2 &
• Amir Reza Azizian 1 , 2  

BMC Health Services Research volume  24 , Article number:  793 ( 2024 ) Cite this article

Metrics details

Healthcare systems are transforming into learning health systems that use data-driven and research-informed approaches to achieve continuous improvement. One of these approaches is the use of clinical pathways, which are tools to standardize care for a specific population and improve healthcare quality. Evaluating the maturity of clinical pathways is necessary to inform pathway development teams and health system decision makers about required pathway revisions or implementation supports. In an effort to improve the development, implementation, and sustainability of provincial clinical pathways, we developed a clinical pathways maturity evaluation matrix. To explore the initial content and face validity of the matrix, we used it to evaluate a case pathway within a provincial health authority in Saskatchewan, Canada.

By using iterative consensus-based processes, we gathered feedback from stakeholders including patient and family partners, policy makers, clinicians, and quality improvement specialists, to rank, retain, or remove enablers and sub-enablers of the draft matrix. We tested the matrix on the Chronic Pain Pathway (CPP) for primary care in a local pilot area and revised the matrix based on feedback from the CPP development team leader.

The final matrix contains five enablers (i.e., Design, Ownership and Performer, Infrastructure, Performance Management, and Culture), 20 sub-enablers, and three trajectory definitions for each sub-enabler. Supplemental documents were created for six sub-enablers. The CPP scored 15 out of 40 possible points of maturity. Although the pathway scored highest in the Design enabler (10/12), it requires more attention in several areas, specifically the Ownership and Performer and the Performance Management enablers, each of which scored zero. Additionally, the Infrastructure and Culture enablers scored 2/4 and 3/8 points, respectively. These areas of the CPP are in need of improvement in order to enhance the overall maturity of the CPP.

Conclusions

We developed a clinical pathways maturity matrix to evaluate the various dimensions of clinical pathways’ development and implementation. The goals of this initial work were to develop and validate a tool to assess the maturity and readiness of new or existing pathways and to track pathways' revisions and improvements.

Peer Review reports

Healthcare systems are transforming to become learning health systems (LHS) in which quality care and value are achieved by demonstrating improvements to patient experiences and health outcomes, provider experiences, population health, and health system costs [ 1 ]. In LHS, continuous improvement is achieved by data-driven and research-informed approaches [ 1 , 2 , 3 , 4 , 5 ]. One of these approaches is the utilization of clinical pathways [ 6 , 7 ]. Clinical pathways, also known as critical or integrated care pathways [ 8 ], are operationally defined as tools to standardize care for a specific population, translate guidelines or evidence into local structure, create a structured multidisciplinary care plan, and detail a care plan in an inventory of actions [ 9 , 10 , 11 , 12 ]. Clinical pathways can improve patients' and providers' experience and satisfaction, resource utilization, and inter-professional teamwork while reducing knowledge transition gaps, healthcare team burnout, costs, and variation in care [ 11 , 13 , 14 , 15 ]. Further, clinical pathways can be utilized to improve the domains of healthcare quality including safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability [ 14 , 16 , 17 ].

Implementation barriers such as knowledge users’ awareness, stakeholders’ engagement, information technology (IT) infrastructure, and performance management have been shown to impede optimal integration of clinical pathways into healthcare systems [ 11 , 12 , 13 , 17 , 18 , 19 , 20 ]. To increase their impact, the development and implementation of clinical pathways should be guided by theories, models, or frameworks [ 12 , 21 ]. Despite outlining the development and implementation of clinical pathways, many frameworks do not specify how to evaluate the maturity of pathways. For our purposes, we defined maturity as a dynamic state of planning, development, and readiness for a pathway to be implemented, replicated or scaled up, and sustained in its intended clinical settings in which the goals or outcomes of the pathway are achieved. Evaluating the maturity of clinical pathways can inform pathway development teams and health system decision makers about required pathway revisions or implementation supports to improve implementation outcomes such as acceptability, fidelity, feasibility, adoption, appropriateness, and sustainability [ 22 ]. Further, evaluating the maturity of clinical pathways enhances the effectiveness of clinical pathways by ensuring they are functioning as intended and achieving the planned effects at the patient, provider, and system levels [ 11 ]. To our knowledge, only one paper has been published that describes a formal and standardized process to evaluate the maturity of clinical pathways [ 13 ]. Although the maturity model described by Schriek et al. [ 13 ] provides a foundation for pathway evaluation, the Saskatchewan Health Authority (SHA) Clinical Pathways Core Team (CPCT) aimed to ensure that the purpose of the model, its enablers and sub-enablers and their definitions, and their trajectory definitions are compatible with the SHA environment. The process and results of verifying content and face validity of the proposed matrix through key stakeholders’ engagement and testing the matrix with a case pathway prototype within the SHA in Canada are described.

Serving a diverse population of 1.2 million residents with over 45,000 employees and physicians, the SHA is responsible for delivery of the majority of publicly funded health services throughout the province of Saskatchewan [ 23 ]. The SHA was launched in December 2017 through the amalgamation of 12 former health regions. The Clinical Excellence portfolio of the SHA is responsible for the development, implementation, and evaluation of new clinical pathways that guide clinical care for targeted conditions [ 24 ]. The SHA currently has clinical pathways for Acute Stroke, Bariatric Surgery, Chronic Pain, Fertility Care, Hip and Knee Replacement Surgery, Lower Extremity Wounds, Multiple Sclerosis, Pelvic Floor, Prostate Cancer, and Spine [ 24 ]. Additionally, there are pathways for Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and Long COVID that are in development (Table  1 ). These pathways have been or are being developed by multidisciplinary stakeholder teams consisting of operational leaders, clinical experts, and patient and family partners (PFPs) [ 24 ].

In 2021, nine pathways developed by the Saskatchewan Ministry of Health (MoH) were transitioned to the SHA, for a total of 13 pathways that fall within SHA accountability (Table  1 ). At a provincial level, this accountability includes the responsibility of supporting development and implementation, maturing of clinical pathways, and progress reporting to the MoH. As the former MoH pathways were developed without a standardized approach, they varied in their design and scale (provincial versus local settings). Gaps were recognized in that no processes, tools, or methods existed to validate the maturity of each pathway, to compare the pathways to one another, and to provide progress reporting to the MoH. The SHA CPCT planned to develop a maturity evaluation matrix to bridge these gaps by providing a tool that could measure levels of maturity via design, awareness, usage, metrics inclusion, owner engagement and participation, and provincial replicability of the clinical pathways.

Developing the maturity matrix

A search of published English language literature in MEDLINE via Pubmed, CINAHL, Cochrane Library, and Google Scholar for maturity evaluation matrices or models for clinical pathways resulted in identification of only one relevant publication [ 13 ]. The maturity matrix published by Schriek et al. [ 13 ] contained five enablers and 19 weighted sub-enablers with four trajectory definitions (low, moderate, high, and top) for each sub-enabler. The matrix was initially examined and evaluated by the SHA CPCT to determine its compatibility within the specific context of Saskatchewan. Our CPCT included members with various backgrounds (medicine, quality improvement, implementation science, learning health systems, research, and psychology) as well as a pathway development team leader. The assessment of Schriek et al.’s matrix revealed the need to modify it based on the current knowledge in the fields of quality improvement, implementation science, and evaluation. For example, sub-enabler definitions and their trajectories required revisions to improve their clarity, potential translation issues were addressed and language was refocused to be patient-centered, a dedicated sub-enabler was added to capture the intricacies of the patient journey, and the complexity of the maturity scoring was simplified allowing evaluators to better distinguish between levels.

Using an iterative consensus-based process, email invitations (one initial and one reminder email two weeks later) were sent to SHA and MoH stakeholders with differing levels of experience in clinical pathway development and implementation as well as PFPs. Both emails were sent from the Director of Clinical Excellence in July 2022 with an attached copy of the draft maturity matrix (Fig.  1 ). We used purposeful and snowball sampling methods to identify the stakeholders from SHA and MoH. They came from diverse disciplines within the SHA, including nursing, executive directors, managers, clinical department heads, physicians, administrators, and a pathway developer from the MoH. Knowledge of pathway development among stakeholders ranged from those that had been involved with development and utilization of pathways to those that had moderate to no exposure in this area. To identify the PFPs, we asked the SHA or MoH stakeholders to recommend PFPs who they had previously worked with as well as contacted the SHA’s Patient and Client Experience (PCE) department [ 25 , 26 ]. All PFPs were registered with the SHA’s PCE department and were compensated as per the organization’s PFP policy [ 26 , 27 ]. Knowledge of pathway development among the PFPs ranged from involvement with pathway development and related concepts to no previous exposure in this area. Beyond diversity in professional roles, the stakeholders and PFPs included individuals of different ages, genders, ethnicities, and immigration backgrounds, reflecting a range of lived experiences and perspectives.

Development of maturity matrix and iterative consensus-based processes

The stakeholders and PFPs were asked to review the draft maturity matrix, determine which enablers and sub-enablers of the matrix should be kept and weighted more importantly on a 10-point Likert scale, choose which sub-enablers to be removed, and complete a REDCap (Research Electronic Database Capture) questionnaire (Supplementary file 1) [ 28 , 29 ]. Sub-enablers with a mean of 7 to 10 were considered important for inclusion.

After receiving the feedback, all potential participants were invited to attend virtual follow-up meetings in September 2022 via Webex platform [ 30 ]. Participation was voluntary and no identifiable information was collected during the virtual meetings (Fig.  1 ).

During the sessions with the SHA and MoH stakeholders, questions were posed to participants about the inclusion of categories integral to pathway development, including pathway ownership (i.e., owner identity), patient involvement (e.g., ongoing stakeholder engagement), provincial integration (e.g., network of pathways) and replication (e.g., capacity monitoring). Content and face validity related to the relevance, appropriateness, and utility of the tool were explored and verified through discussions regarding the purpose of the tool and potential end users.

The session with PFPs had a series of seven questions seeking patients’ perspectives (five general questions and two questions related to the importance of sub-enablers) (Table  2 ). The questions were designed in consultation with the SHA’s PCE department and based on the SHA’s “Setting the stage for successful meetings with patient family partners (PFPs)” guidelines (internal document). Highlights of the guidelines include building in sharing time (ice breakers, stories), avoiding medical jargon or acronyms, and listening to PFPs stories, even if they are about care that did not go well. We started with open ended questions about PFPs’ experience in pathways or Saskatchewan’s health system and asked questions related to what is important to them in their care (i.e., pathway outcomes). To ensure the use of plain language and avoid using jargon, the CPCT conducted a readability analysis on the matrix. Results indicated that the matrix was at the university graduate level on the Flesch Readability Scale. Given this, the CPCT decided to focus on overarching concepts instead of one by one sub-enabler review. This was done to promote PFP’s engagement in an open and inviting discussion.

Notes were taken during the meetings and summarized to participants who then provided additional feedback or context and validated the summary.

It is important to note that, while we chose to begin testing the use of the maturity matrix after the above rounds of development and refinement, the document is intended to be dynamic and continuously evolving based on feedback, context, and experience. While we have finalized the tool for current use, we remain open to future revisions to ensure its efficacy in improving pathways. The current goal is to maintain stability for a period of time to facilitate practical application, testing, and evaluation.

Applying the maturity matrix

We chose the Chronic Pain Pathway (CPP) because it was a newly developed pathway that had not been put into practice across the province. Using the Webex platform, the CPCT and the CPP development team leader met virtually from June to September 2022 (first round) and used the draft matrix to evaluate the CPP. The draft matrix contained 19 sub-enablers, each with four trajectories (low, moderate, high, and top). The purpose of the first round evaluation was to focus on the utility, clarity, and applicability of the draft matrix’s various components and scoring definitions (Fig.  1 ). From February to March 2023 (second round), the CPCT asked the pathway leader for her input on the elements of the revised maturity matrix, which contained 20 sub-enablers with three trajectories (low, moderate, and high). For this round of evaluation, we wanted to know if the terminology was relevant and if the matrix could be effectively used to rate the development of the pathway.

Based on our experience, we recommend the assembly of a diverse assessment team comprising of individuals with various backgrounds to complete a clinical pathway evaluation. This team may include patient and family partners, clinical experts, pathway developers, administrators, operational staff, quality improvement experts, implementation experts, researchers, administrative personnel, information technology experts, and policy makers. Assessments should adopt an iterative process of current state assessment and should be conducted regularly (e.g., annually) through a series of collaborative meetings where team members systematically review components of the pathway matrix and discuss the status of the pathway for each sub-enabler based on data collected over the year. Supplementary documents should be reviewed for relevance and teams should score the sub-enablers based on the defined trajectories. In the event of a disagreement among team members regarding a particular score, we recommend employing consensus-based approaches to resolution, ensuring that divergent viewpoints are acknowledged and reconciled through constructive dialogue.

Design and structure of the maturity matrix

Thirty-seven people (32 SHA and MoH stakeholders and five PFPs) were invited to participate via email. Fourteen responses were received from the REDCap questionnaire (response rate = 38%). The mean score for importance of all sub-enablers was 7.9/10 (mean range: 7 – 9, SD: 1.8).

Two virtual follow-up meetings (two hour sessions) with 11 SHA and MoH stakeholders (all 32 stakeholders were invited) and one (two hour session) with three PFPs (all five PFPs were invited) were held. During the follow-up meetings with SHA and MoH stakeholders, the attendees emphasized the importance of and equal weighting for all sub-enablers in the maturity matrix, resulting in the inclusion of all in the final matrix. During the follow-up meeting with PFPs, there was agreement that all sub-enablers were of equal relevance. The importance of categories representing patient preferences was highlighted, including multidisciplinary care (Ongoing Stakeholder Engagement sub-enabler), standardization in care (Design Approach sub-enabler), evidence based approaches (Compliance sub-enabler), and ease of navigation (Clarity in the Decision Criteria sub-enabler), all of which had been considered during the development of the matrix.

Based on the feedback received during the follow-up sessions, the CPCT added a “Patient Journey Map” sub-enabler under the “Design” enabler (resulting in 20 sub-enablers), reduced trajectory categories to three (low, moderate, and high), rearranged the order of sub-enablers, and modified the definitions of two enablers and eight sub-enablers to align with the needs of the SHA context (Table  3 ). A full list of maturity matrix enablers, sub-enablers, their definitions, and the three trajectory definitions are presented in Supplementary file 2.

Since all sub-enablers of the maturity matrix were considered to be of equal importance by the stakeholders and PFPs, we did not incorporate weighting the sub-enablers as had been done in the maturity matrix that we modelled our work on [ 13 ]. Therefore, we used a simple sum of the sub-enablers’ maturity levels (low = 0, moderate = 1, and high = 2) to score maturity of a pathway. This results in minimum and maximum scores of 0 and 40, respectively.

During the revisions of the maturity matrix by the CPCT and the feedback received from stakeholders, the need was identified to develop supplemental documents for six sub-enablers (Pathway Objective Alignment, Compliance, Design Approach, Network of Pathways, Capacity Monitoring, and Adaptability). These documents were either adapted from other sources (e.g., SHA’s measurement planning templates), or templates were developed ad hoc (Table  4 ). The supplemental document templates are provided in Supplementary files 3 to 8.

Scores of chronic pain pathway evaluation

The CPP development team leader and the CPCT met virtually in two rounds of meetings (i.e., seven meetings total) (Fig.  1 ) and scored the pathway twice. The first round of CPP scoring (four meetings, 6.5 h in total) resulted in a score of 18/57 (19 sub-enablers with four trajectory definitions [low = 0, moderate = 1, high = 2, and top = 3]) (Table  5 ). The CPP scored highest in Design (11/15), followed by Culture (4/12), Infrastructure (1/6), Owner and Performer (1/6), and Performance Management (1/18). The score was 15/40 in the second round (three meetings, 4.5 h in total), with the highest score in Design (10/12), followed by Infrastructure (2/4), Culture (3/8), Owner and Performer (0/4), and Performance Management (0/12) (Table  5 ).

We developed a maturity evaluation matrix for clinical pathways based on a previously published matrix in which a generic business process maturity model was utilized [ 13 ]. We refined the previous matrix using iterative consensus-based processes that included a questionnaire and multiple group discussions with PFPs, policy makers, clinicians, and quality improvement specialists. All enablers from the previous matrix were retained, but 16/19 sub-enablers were modified and one sub-enabler (i.e., Patient Journey Map) was added.

The existing literature on this topic is limited, which has underscored a significant gap concerning the absence of a comprehensive tool for evaluating the maturity of clinical pathways. This proposed maturity matrix is specifically designed to support clinical pathway development and implementation teams in assessing various aspects of pathway maturity. These aspects include a) Pathway design: This includes factors such as clinical components, objectives of care delivery, adherence to evidence-based practices, and the extent of stakeholder involvement; b) Ownership: This category involves aspects such as leadership engagement and involvement, the assessment of role awareness, and the functionality of different roles within the pathway; c) Infrastructure: This pertains to the integration of infrastructure, both internally and externally, for disseminating information and the connectivity of the pathway to other relevant pathways; d) Performance Management: This encompasses the selection and utilization of metrics, the availability and collection of data, data usage, and planning for provincial replication; and e) Culture: This focuses on elements like pathway awareness, stakeholder engagement, the capability for provincial implementation, and the audit and evaluation process.

To facilitate this evaluation, completion of the supplemental documents contained within the matrix is required. For instance, the Clinical Pathway Listing document aids in assessing whether connections or overlap with other pathways were considered during the development and implementation of the pathway currently under review.

By using our proposed scoring tool, a clinical pathway development team can compare the score of the pathway with previous scores to ensure that the score is improving over time. Further, health system decision makers are able to compare different pathways or examine low scores for commonalities amongst multiple pathways to identify resource needs and systemic issues. For example, if all pathways score low in the Owner (Identity) sub-enabler, it may indicate sponsorship constraints for clinical pathways in an organizational structure that may impact the sustainability of pathways. Further research is needed to understand the interpretation of the total score and whether a threshold score can be identified for satisfactory maturity. At present, pathway development teams are encouraged to make decisions based on individual sub-enabler scores and to use total scores as an overall measure of pathway maturity.

It is important for all healthcare interventions to incorporate aspects of equity, diversity, and inclusion (EDI) into their development and implementation. While these are not explicitly sub-enablers in the current version of the maturity matrix, several components within the matrix incorporate considerations for EDI. For example, the patient journey map, provincial service planning (using supplemental tools such as capacity monitoring), and engagement of diverse patient and family partners and a multidisciplinary team for pathway development inherently encompass aspects of EDI. As future iterations of the maturity matrix are evaluated and modified, inclusion of EDI as a specific sub-enabler may be considered.

Our evaluation showed areas in which the CPP can be improved as well as areas that the matrix can guide further development of the CPP. For example, the CPP scored highest in Design, which may reflect the status of the pathway during the assessment. The CPP has been fully developed but only implemented within one local setting, with plans to be implemented provincially. In addition, the pathway was scored during a time of leadership change within the SHA, leaving a temporary gap in pathway ownership. This status impacted the pathway’s scores for elements such as sponsorship, owner identity, role awareness, connectivity, data collection, provincial replication, and ongoing adaptability. Low scores in the CPP infrastructure and performance management may reflect gaps in organizational investment in resources to support implementation and evaluation of clinical pathways.

During the follow-up sessions, the participants indicated that all sub-enablers held equal significance. This differs from the findings of Schriek et al. wherein weights were incorporated into the analysis through stakeholder consultations [ 13 ]. The difference in weighting may be attributed to various factors, such as the revisions we made to the original maturity matrix, differences in methodological approaches (our study's utilization of the consensus-based approach versus the Delphi approach employed by Schriek et al.), and variations in the stakeholders involved. While opting for a non-weighted maturity scoring approach offers simplicity, it may not fully reveal the nuanced distinctions between the sub-enablers. Future studies could play a crucial role in unraveling the potential benefits of adopting a weighted scoring approach.

Limitations

Several limitations should be noted in our study. First, we did not include developers from different clinical pathways in the development of the matrix, which may limit the generalizability of our results. Additionally, we did not have a PFP in our CPCT, which could have provided valuable input from the patient perspective. To mitigate these limitations, we used an iterative consensus-based approach to gather input from a diverse group of stakeholders in developing the matrix.

We considered higher scores as improvements in pathways’ maturity. However, this may not be a reflection of reality. Currently, there is no gold standard by which to measure the accuracy of enablers or sub-enablers of our maturity matrix. At this stage, it was considered critical to ensure that stakeholders agreed on what enablers or sub-enablers were important to observe and how to differentiate between strong and weak performance in those attributes (i.e., content and face validity). Stakeholders agreed that all relevant elements of pathway maturity were included in the enablers and sub-enablers and that measurement trajectories were appropriate. Reviewing the CPP with the CPP development team leader seemed to confirm the face validity of the matrix because it was considered by a targeted end user as effective in measuring maturity (i.e., dynamic state of planning, development, and readiness for a pathway to be implemented, replicated or scaled up, and sustained in its intended clinical settings).

Future direction

There are several areas for future research related to our clinical pathways maturity matrix. First, we did not perform test–retest or inter-rater reliability testing of the matrix, and therefore future studies should evaluate the matrix’s reliability and validity. Further evaluation is needed to determine if the matrix is able to predict pathway progression to future improved state and successful implementation. To do this, the CPCT will monitor pathway development and implementation using the matrix and whether additional elements of pathway maturity emerge with more widespread use of the matrix.

Second, our study highlights the need for standardized measures for performance management of pathways (e.g., length of stay, patient reported experience measures, and patient reported outcome measures). However, IT support is needed to access data. Future research should explore the data access barrier and examine its impact on pathway implementation.

Finally, future versions of the matrix could include implementation, service, and client outcomes, such as pathway adoption, sustainability, or stakeholder satisfaction [ 22 ]. These outcomes would provide a more comprehensive picture of the pathway's maturity and impact. It is worth noting that several tools can supplement the clinical pathways maturity matrix, adding complexity, sophistication, and efficacy to the evaluation process. While the focus of this study was on the development and testing of the matrix, it is important to acknowledge the value of these supplementary tools. Future research could explore the integration of these tools into the evaluation process and their impact on the accuracy and utility of the matrix.

The SHA Clinical Pathways Core Team (CPCT) has developed a maturity matrix that can serve as a tool for evaluating both new and existing clinical pathways. This matrix plays a role in evaluating the design quality of pathways and identifying gaps and limitations in their implementation and replication. We believe that our matrix enables development and implementation teams to monitor clinical pathways over time to ensure they are achieving their intended effects at multiple levels, including the patient, provider, and system levels. This comprehensive evaluation warrants that clinical pathways align with their objectives and deliver value across the healthcare systems.

Further research will be necessary to determine the real-world impact of implementing this matrix. We aim to investigate whether utilizing the matrix leads to improved clinical pathways and whether it can effectively identify when a pathway is ready for implementation. By doing so, we hope to contribute to the ongoing improvement of clinical care, enhancing patient outcomes, provider satisfaction, and the efficiency of healthcare delivery.

Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

Clinical Pathways Core Team

Chronic Pain Pathway

Learning Health Systems

Saskatchewan Ministry of Health

Patient and Client Experience

Patient and Family Partners

Quality Improvement

Saskatchewan Health Authority

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Acknowledgements

The authors would like to thank participants of the study’s sessions.

The Patient and Family Partners (PFPs) received funding from Saskatchewan Health Authority’s Patient and Client Experience (PCE) Department via their MyImpact account where they log their hours of participation and receive compensation as per the SHA’s PFP policy.

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Crystal Lynn Larson, Jason Robert Vanstone, Taysa-Rhea Mise, Susan Mary Tupper, Gary Groot & Amir Reza Azizian

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CLL, JRV, TRM, SMT, GG, and ARA led the conceptualization of the study. CLL, JRV, TRM, SMT, and ARA contributed to analysis of the results and writing of the manuscript. All authors contributed to the study’s methodology, interpretation of the findings, and revision of the manuscript. All authors read and approved the final manuscript.

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Larson, C.L., Vanstone, J.R., Mise, TR. et al. Development and validity testing of a matrix to evaluate maturity of clinical pathways: a case study in Saskatchewan, Canada. BMC Health Serv Res 24 , 793 (2024). https://doi.org/10.1186/s12913-024-11239-x

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• Clinical pathways
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BMC Health Services Research

ISSN: 1472-6963

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• Introduction
• Conclusions
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Data were from a multimodal (telephone + internet) survey of nonelderly US citizens (aged 19-64 years) who lived in 1 of 4 Southern states (Arkansas, Kentucky, Louisiana, and Texas) and reported 2022 household incomes less than 138% of the federal poverty line and that they and/or a dependent child (if any) had been enrolled in Medicaid at some point since March 2020. The survey was fielded from September to November 2023. Percentages may not sum to 100 due to rounding. All reported estimates were survey-weighted.

Survey-weighted rates of coverage at the time of the interview among people who reported disenrolling from Medicaid. Data were from a multimodal (telephone + internet) survey of nonelderly US citizens (aged 19-64 years) who lived in 1 of 4 Southern states (Arkansas, Kentucky, Louisiana, and Texas) and reported 2022 household incomes less than 138% of the federal poverty line and reported that they had been enrolled in Medicaid at some point since March 2020. The survey was fielded from September to November 2023. Percentages may not sum to 100 due to rounding. All reported estimates were survey-weighted. ESI indicates employer-sponsored insurance.

Adjusted predicted probabilities (estimated using Stata’s “margins” command with default settings [StataCorp]) from a logistic regression using the same covariates reported in Table 2. Data were from a multimodal (telephone + internet) survey of nonelderly US citizens (aged 19-64 years) who lived in 1 of 4 Southern states (Arkansas, Kentucky, Louisiana, and Texas) and reported 2022 household incomes less than 138% of the federal poverty line and reported that they had been enrolled in Medicaid at some point since March 2020. The survey was fielded from September to November 2023. Percentages may not sum to 100 due to rounding. All reported estimates are survey-weighted.

eMethods. Additional Detail on Survey Sample, Response Rates, Weighting, and Survey Question Wording

eAppendix. Background on State Unwinding Policies

eTable 1. Factors Associated with Disenrollment from Medicaid Since March 2020, Stratified By State

eTable 2. Factors Associated with Child Disenrollment from Medicaid Since March 2020

eTable 3. Factors Associated with Losing Medicaid and Becoming Uninsured

eFigure 1. Medicaid Enrollment Status at Time of Interview, Among Respondents Ever in Medicaid Since March 2020, Stratifying by Health Status, Chronic Conditions, and Disability Status

eFigure 2. Affordability and Access to Care Among Adult Medicaid Enrollees versus Disenrollees, Stratified by Current Coverage Status

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McIntyre A , Sommers BD , Aboulafia G, et al. Coverage and Access Changes During Medicaid Unwinding. JAMA Health Forum. 2024;5(6):e242193. doi:10.1001/jamahealthforum.2024.2193

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Coverage and Access Changes During Medicaid Unwinding

• 1 Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
• 2 Harvard Medical School, Boston, Massachusetts
• 3 Brigham and Women’s Hospital, Department of Medicine, Boston, Massachusetts

Question   How did insurance coverage and access to care change among low-income households during the Medicaid unwinding process?

Findings   In this survey study of US low-income households in 4 Southern states in late 2023, 1 in 8 respondents who had Medicaid reported exiting the program roughly 6 months into the unwinding process, with wide state-level variation in coverage loss. Roughly half of those in the sample who lost Medicaid coverage became uninsured.

Meaning   The results of this study suggest that state and federal policymakers should pursue policies to mitigate adverse outcomes associated with coverage disruptions during and after Medicaid unwinding.

Importance   States resumed Medicaid eligibility redeterminations, which had been paused during the COVID-19 public health emergency, in 2023. This unwinding of the pandemic continuous coverage provision raised concerns about the extent to which beneficiaries would lose Medicaid coverage and how that would affect access to care.

Objective   To assess early changes in insurance and access to care during Medicaid unwinding among individuals with low incomes in 4 Southern states.

Design, Setting, and Participants   This multimodal survey was conducted in Arkansas, Kentucky, Louisiana, and Texas from September to November 2023, used random-digit dialing and probabilistic address-based sampling, and included US citizens aged 19 to 64 years reporting 2022 incomes at or less than 138% of the federal poverty level.

Exposure   Medicaid enrollment at any point since March 2020, when continuous coverage began.

Main Outcomes and Measures   Self-reported disenrollment from Medicaid, insurance at the time of interview, and self-reported access to care. Using multivariate logistic regression, factors associated with Medicaid loss were evaluated. Access and affordability of care among respondents who exited Medicaid vs those who remained enrolled were compared, after multivariate adjustment.

Results   The sample contained 2210 adults (1282 women [58.0%]; 505 Black non-Hispanic individuals [22.9%], 393 Hispanic individuals [17.8%], and 1133 White non-Hispanic individuals [51.3%]) with 2022 household incomes less than 138% of the federal poverty line. On a survey-weighted basis, 1564 (70.8%) reported that they and/or a dependent child of theirs had Medicaid at some point since March 2020. Among adult respondents who had Medicaid, 179 (12.5%) were no longer enrolled in Medicaid at the time of the survey, with state estimates ranging from 7.0% (n = 19) in Kentucky to 16.2% (n = 82) in Arkansas. Fewer children who had Medicaid lost coverage (42 [5.4%]). Among adult respondents who left Medicaid since 2020 and reported coverage status at time of interview, 47.8% (n = 80) were uninsured, 27.0% (n = 45) had employer-sponsored insurance, and the remainder had other coverage as of fall 2023. Disenrollment was higher among younger adults, employed individuals, and rural residents but lower among non-Hispanic Black respondents (compared with non-Hispanic White respondents) and among those receiving Supplemental Nutrition Assistance Program benefits. Losing Medicaid was significantly associated with delaying care due to cost and worsening affordability of care.

Conclusions and Relevance   The results of this survey study indicated that 6 months into unwinding, 1 in 8 Medicaid beneficiaries reported exiting the program, with wide state variation. Roughly half who lost Medicaid coverage became uninsured. Among those moving to new coverage, many experienced coverage gaps. Adults exiting Medicaid reported more challenges accessing care than respondents who remained enrolled.

As part of the COVID-19 federal public health emergency, states paused Medicaid disenrollment in exchange for increased federal funding, allowing Medicaid beneficiaries to remain continuously enrolled without eligibility redeterminations. 1 This policy was associated with record historic growth in Medicaid and the Children’s Health Insurance Program (CHIP), increasing from roughly 72 million in March 2020 to more than 92 million people by December 2022. 2 - 6 In late 2022, Congress passed legislation to end the continuous coverage provision; states resumed eligibility redeterminations in early and mid 2023. 7

Initial projections suggested that this unwinding of continuous coverage would be followed by 15 to 18 million people losing Medicaid benefits. 8 However, by early May 2024, the number of people disenrolled from Medicaid exceeded 21 million. 9 Most people who have lost Medicaid thus far (70%) were disenrolled due to administrative or procedural reasons, which include the inability or failure to complete paperwork, rather than confirmed loss of eligibility. 9 Policies governing this process and disenrollment rates vary considerably by state. 10 , 11

While administrative data show the number of enrollees losing Medicaid coverage, they do not track enrollees’ coverage transitions nor offer insights into how unwinding is associated with enrollees’ access to and affordability of medical care. 12 High-quality federal surveys will eventually illuminate some of these dynamics, but these data are subject to considerable time lag. 13

To provide timely insights into how Medicaid unwinding affects individuals in the US experiencing low income, we conducted a multimodal survey of adults in 4 states during late 2023. Respondents were US citizens who reported 2022 incomes less than 138% of the federal poverty line (FPL). The survey assessed changes in insurance coverage and access to care.

The 4 states in our sample (Arkansas, Kentucky, Louisiana, and Texas) took varied approaches to unwinding. Arkansas conducted redeterminations on an accelerated 6-month timeline; most states took a year. 14 Kentucky and Louisiana spread redeterminations evenly across 12-month schedules; however, Kentucky halted redeterminations for children for a year, extending their continuous coverage while unwinding was underway for adults. 15 - 17 Texas conducted redeterminations over a full year, prioritizing cases thought likely to be ineligible, and aiming to conduct most redeterminations during the first 6 months. 18 The federal government allowed states to waive certain requirements to implement strategies to improve the retention of eligible enrollees during unwinding; the number of these optional strategies pursued by states in the sample ranged from 4 (Texas) to 14 (Kentucky). 49 Additional details on the unwinding policies of states are available in Supplement 1 .

We conducted a representative survey of US citizens with low incomes in 4 Southern states (Arkansas, Kentucky, Louisiana, and Texas) between September 18, 2023, and November 21, 2023. The survey primarily recruited respondents through random-digit dialing (using cellular and landline telephones) and probabilistic address-based sampling (ABS). Respondents recruited through ABS received postcards inviting them to participate in the survey by phone or on the internet. A small proportion of the sample was recruited using the survey vendor’s nationally representative probability-based web panel or by contacting individuals probabilistically recruited for prior unrelated research. Informed consent was obtained directly through the online survey format or verbally for those participating by phone. The study followed American Association for Public Opinion Research ( AAPOR ) reporting guidelines and was approved by the Harvard T.H. Chan School of Public Health institutional review board.

The sample contained US citizens aged 19 to 64 years who reported family incomes in 2022 less than 138% of the FPL. This income criterion reflects the eligibility threshold for Medicaid in states that have expanded the program under the Affordable Care Act. The survey oversampled respondents who self-identified as Black or Hispanic to facilitate investigation of potential racial disparities. We also oversampled Texas (the lone nonexpansion state) and Arkansas (the first of these states to resume Medicaid redeterminations in 2023).

This study was a continuation of repeated cross-sectional surveys in these states, and previous research demonstrated that this survey approach has produced state-level coverage trends that closely track with subsequent data from the US Census Bureau. 19 Additional information about survey design is in Supplement 1 .

The survey collected information on demographic characteristics (including self-reported race and ethnicity), current health insurance, and access to care. We also asked respondents whether they had been enrolled in Medicaid at any point since March 2020, when continuous coverage began. Respondents with dependent children (younger than 19 years) were asked about their child’s insurance at the time of the interview and whether the child had any Medicaid/CHIP coverage since March 2020. Survey items were primarily drawn from prior versions of this survey, which adapted from federal government surveys or recent survey questions used by KFF and Urban Institute. 20 - 22

Among respondents (and, when applicable, their children) who had Medicaid coverage at any point since March 2020, the primary outcome was self-reported disenrollment from Medicaid (that is, not reporting Medicaid coverage at the time of the interview). Secondary outcomes were current health care coverage among Medicaid disenrollees (Medicare, employer-sponsored insurance, marketplace insurance, other coverage, or uninsured), whether respondents had experienced a gap in coverage (lasting 1 month or longer) during the previous year, and several measures of access to and affordability of care: delayed care during the previous year due to cost, delayed medications during the previous year due to cost, reporting care was less affordable than a year ago, and whether a person had a checkup during the previous year. Exact survey question wording is available in the eMethods in Supplement 1 .

First, we summarized characteristics of the full sample and subset of respondents who reported having Medicaid coverage since March 2020. We then estimated rates for the primary outcome, loss of Medicaid, stratifying by state for adult respondents. To assess the validity of our results, we compared state-level Medicaid losses reported in the sample with Medicaid disenrollment rates in administrative data that were concurrent with the timing of our survey and estimated the correlation coefficient for those estimates. We then evaluated insurance at the time of the survey among adult respondents reporting Medicaid disenrollment and whether respondents had a gap in coverage during the previous year.

Using multivariate logistic regression, we separately examined factors associated with Medicaid loss among adults and children (for children, we excluded Kentucky from this model, since it did not disenroll any children in 2023). The covariates were state of residence; demographic characteristics, including race and ethnicity, age, education, employment, income, and parental status (for adults); receipt of Supplemental Security Income (SSI), receipt of Supplemental Nutritional Assistance Program (SNAP) benefits (which may be associated with an increased likelihood that a person had been in contact with state agencies or that the state had adequate income information for their eligibility redetermination); and whether the respondent had moved since March 2020 (which may have been associated with a reduced likelihood that a person received renewal paperwork). 23 , 24

We then used a multivariate logistic regression (adjusting for the previously described covariates) to compare access and affordability measures among respondents who exited Medicaid vs those who remained enrolled in the program. All analyses were survey weighted using state-specific benchmarks derived from federal data for the demographic variables listed in the previously described models; each state was weighted in proportion to its share of the sample (ie, more populous states were not weighted more heavily). Weights also adjusted for modality and nonresponse. Statistical analyses were conducted using Stata, version 17 (StataCorp); significance was determined at the 5% level.

The survey sample comprised 2210 respondents; 1471 (66.6%) reported Medicaid enrollment since March 2020 themselves, and 766 (34.7%) reported child Medicaid enrollment (636 respondents reported Medicaid for themselves and a child). A total of 1155 respondents (52%) were recruited through ABS and 930 (42%) through random-digit dialing; the rest were recruited from the vendor’s prior surveys (85 [4%]) or a probability-based web panel (40 [2%]). The overall response rate was 5%.

A total of 1282 participants (35.8%) resided in Texas and 728 (32.9%) in Arkansas, with the remainder split between Kentucky (351 [15.9%]) and Louisiana (791 [15.4%]). Before weighting, 27.8% (n = 616) of the sample self-identified as non-Hispanic Black, 18.2% (n = 402) as Hispanic, 46.5% (n = 1028) as non-Hispanic White, and 7.4% (n = 164) as another race (including Asian, American Indian or Alaskan Native, and Hawaiian or other Pacific Islander).

After applying survey weights, 1564 (70.8%) reported that either they and/or a dependent child had been enrolled in Medicaid at some point since March 2020. Table 1 presents summary statistics for the full study sample and the subset of the sample reporting Medicaid enrollment since March 2020.

Overall, 12.5% (n = 179) of adults who had Medicaid at some point since March 2020 were no longer enrolled by fall 2023, ranging from 7.0% (n = 19) in Kentucky to 16.2% (n = 82) in Arkansas ( Figure 1 ), with Louisiana (23 [8.2%]) and Texas (54 [14.9%]) falling in between. Fewer dependent children (42 [5.4%] overall) lost Medicaid coverage. The state-level estimates of adult coverage loss were strongly correlated with administrative records of coverage loss in late 2023 (ρ = 0.92); additional details are available in the eAppendix in Supplement 1 .

Among adults who lost Medicaid coverage (n = 168), just fewer than half (80 [47.8%]) were uninsured at the time of the interview ( Figure 2 ), while 52.2% had other coverage. Among disenrollees, 27% (n = 45) reported having insurance through an employer, 13% (n = 22) Medicare, 9.7% (n = 16) Marketplace coverage, and 2.6% other insurance.

Roughly half of those who transitioned to employer or marketplace coverage reported coverage gaps during the prior year. Overall, and including those who became uninsured, only 49 respondents (29.3%) who lost Medicaid transitioned to new coverage without a gap. Among respondents who had Medicaid coverage at the time of the interview, 195 (15.5%) reported a coverage gap during the prior year, potentially reflecting churn in and out of the program.

Table 2 shows factors associated with disenrollment from Medicaid between March 2020 and fall 2023. Disenrollment was significantly higher among individuals in Arkansas than in Louisiana and Kentucky, although this difference only remained significant in Kentucky vs Arkansas after multivariate adjustment. Disenrollment was significantly higher among younger adults, rural individuals, those who were employed, and White adults (compared with non-Hispanic Black adults), although this last difference was significant only in the unadjusted analysis. Individuals receiving SNAP benefits were significantly less likely to disenroll. Moving and having an income greater than 100% of the FPL during the prior year were significant risk factors for disenrollment, while SSI was associated with lower disenrollment, but all 3 were only significant in unadjusted models. Among children (eTable 2 in Supplement 1 ), Arkansas had significantly higher disenrollment rates than the other states (Kentucky was excluded from this analysis, since it had 0% disenrollment by state decision in 2023), while being enrolled in SNAP was highly protective against disenrollment.

Characteristics among adults of being uninsured at time of interview after exiting Medicaid were generally similar as those for Medicaid disenrollment (regardless of coverage at the time of the interview) in unadjusted analyses, except there were no significant differences by race and ethnicity or income, and women were significantly more likely to become uninsured than men (eTable 3 in Supplement 1 ). In adjusted analyses, coefficients associated with state of residence, age, employment, and SSI receipt remained significant.

Figure 3 shows several measures of affordability and access to care, comparing adults who remained enrolled in Medicaid with those who disenrolled from Medicaid. For all 4 measures, adults who disenrolled had significantly worse access and/or affordability, which included more cost-related delays in care (50.8% vs 26.5%), more delays or skipped doses of medications due to cost (44.8% vs 27.1%), reporting that care was less affordable than during the year before (46.5% vs 22.3%), and less likely to have had a checkup during the prior year (57.0% of those disenrolled had no checkup vs 33.6% of people who had Medicaid at time of the interview). Results were generally similar for those who became uninsured vs those with new, non-Medicaid coverage (eFigure 2 in Supplement 1 ).

In this survey of low-income households in 4 Southern states in late 2023, we find that roughly 6 months into the unwinding process, 1 in 8 Medicaid beneficiaries reported exiting the program, nearly half of these adults became uninsured, and those leaving Medicaid experienced more disruptions in medical care than those who remained enrolled. Disenrollment was highest in Arkansas, which started redeterminations earlier than the other states and conducted unwinding on an accelerated 6-month timeline. Texas had the next highest disenrollment rate, likely reflecting the fact that it was the only nonexpansion state in our sample, meaning a much smaller share of nonelderly adults in the state qualify for the program; Texas also frontloaded redeterminations for likely ineligible individuals. The lowest disenrollment rates were in Kentucky and Louisiana, which are expansion states that spread their renewals over the full year and used outside data sources to limit the burden on beneficiaries to demonstrate ongoing eligibility. 25 , 26 This general pattern resembled findings from a recent analysis of administrative data for all 50 states, which found a significant association between disenrollment rates and policies, including Medicaid expansion, alternative data sources for eligibility assessment, and redetermination timing. 11

Children in the sample were less than half as likely to lose Medicaid than adults. This may partially reflect state policy choices: Kentucky suspended redeterminations for enrollees 19 years or younger for 12 months. 17 In addition, the income inclusion criteria for the survey, which was less than 138% of the FPL, did not capture many children enrolled in Medicaid or CHIP who may be more likely to have lost coverage than children in lower-income households. Nonetheless, because children represent nearly half of all enrollees in Medicaid and CHIP, these results suggest that millions of children are losing coverage nationally. 27

We found that 48% of respondents who reported leaving Medicaid said they were uninsured at the time of the interview. While the remainder moved into new sources of coverage, slightly less than half of those who gained private insurance experienced a coverage gap. Prior research has found that even brief coverage gaps have been associated with disruptions in care and adverse health outcomes. 20 , 28 - 32 Our survey study found higher rates of delays in care and challenges with affordability among those leaving Medicaid during unwinding that were consistent with this literature, although these findings were only correlational. 20 , 28 , 30 - 33 While the unwinding process is a key area of focus in 2024, broader issues of continuity of coverage in Medicaid preceded the continuous coverage policy and will persist after the unwinding period ends. 34 Previous research has drawn attention to the frequent disruptions in postpartum coverage in Medicaid as well as churning among children; our findings support the value of ongoing policy efforts to extend continuous eligibility provisions for these populations. 35 - 38

Given the low-income nature of the survey sample, it is likely that many uninsured respondents either remained eligible for Medicaid or would qualify for substantial subsidies to purchase insurance through the Affordable Care Act marketplaces. 39 However, fewer than 1 in 10 respondents who had lost Medicaid coverage had enrolled in a marketplace plan. This modest marketplace take-up rate was consistent with prior research and indicated that more robust outreach and assistance may be required to promote successful transitions into marketplace coverage. 40 - 44

We identified several significant individual-level factors that were associated with Medicaid disenrollment. Younger adults, those who are working and those with higher incomes during the previous year were more likely to lose coverage (although the latter finding was no longer significant after adjustment); these factors may all reflect greater income mobility and help explain why more than a quarter of disenrollees had moved to employer coverage after Medicaid. Disenrollment was higher among rural adults and (in unadjusted analyses) among those who recently moved, which may indicate the difficulties states have reaching such enrollees to help them navigate the redetermination process. Disenrollment rates were higher for White than Black individuals (with Hispanic individuals falling in between) in unadjusted analyses. Other preliminary research on unwinding has found mixed results, with at least 1 study finding lower disenrollment among White beneficiaries; these results may vary based on the states and data sources being examined and require additional future research to assess effects on disparities. 45

Individuals in SNAP were less likely to lose coverage, which may reflect the use of eligibility information from other programs by states to streamline redetermination, as well as greater engagement and awareness of state policies among those participating in multiple programs. SSI participation was also highly protective, although this is expected, given that SSI in these states automatically confers Medicaid coverage; the fact that there was any reported disenrollment from Medicaid among those reporting SSI may reflect respondent confusion over their SSI or Medicaid status, which is consistent with recent studies on coverage awareness during the COVID-19 pandemic. 46 , 47

Our study had several limitations. First, our response rate was much lower than high-quality federal surveys. However, the response rate was similar to other rapid-turnaround surveys (including the US Census Bureau’s Household Pulse Survey), and previous research has validated our survey approach in terms of trends in producing similar trends in state coverage rates as the American Community Survey. 19 This year’s survey included a partial shift to ABS, and our module on children’s coverage is new and should be considered exploratory. Our survey-reported state-level rates of Medicaid disenrollment were highly correlated with concurrent estimates from state administrative data, potentially offering reassurance for our overall approach.

Our sample was limited to residents of 4 Southern states who reported household incomes less than 138% of the FPL in 2022, which may limit generalizability. 11 State approaches to unwinding varied considerably; thus, experiences may have been different in other states. Additionally, many individuals with higher incomes would have been affected by the Medicaid continuous coverage provision and unwinding; about half of children and nonelderly adults who had Medicaid in 2021 had household incomes greater than 138% of the FPL. 48 Because our survey was limited to US citizens, our results also may not generalize to noncitizen permanent residents who qualify for Medicaid in those 4 states.

As with all surveys, there is potential for reporting errors. Some respondents may have been confused about their Medicaid or SSI status or misreported other characteristics or program participation. We conducted the survey in 2023 but asked about 2022 household income to establish eligibility for the survey, following previous versions of our survey, and also capture respondents whose income may have changed over time (potentially affecting Medicaid eligibility during unwinding). However, because of this, we were unable to determine directly whether respondents remained eligible for Medicaid when surveyed or would qualify for other assistance, such as marketplace subsidies. Finally, our analyses were cross-sectional and cannot establish causality.

The findings of this survey study offer early evidence that approximately half of people with low incomes exiting Medicaid during unwinding have become uninsured, while the other half has largely switched to private coverage. State policy choices have been associated with significant differences in rates of coverage loss, which is consistent with the variation in our study’s state-level results. Medicaid loss was associated with greater barriers to accessing medical care. State and federal policymakers should pursue policies to mitigate adverse outcomes associated with coverage disruptions during the unwinding process and in future efforts to improve continuity of care for beneficiaries in Medicaid.

Accepted for Publication: June 3, 2024.

Published: June 29, 2024. doi:10.1001/jamahealthforum.2024.2193

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 McIntyre A et al. JAMA Health Forum .

Corresponding Author: Adrianna McIntyre, PhD, MPH, MPP, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 ( [email protected] ).

Author Contributions: Drs McIntyre and Phelan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: McIntyre, Sommers, Figueroa.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: McIntyre, Aboulafia, Figueroa.

Critical review of the manuscript for important intellectual content: McIntyre, Sommers, Phelan, Orav, Epstein, Figueroa.

Statistical analysis: McIntyre, Sommers, Aboulafia, Phelan, Orav.

Obtained funding: McIntyre, Figueroa.

Administrative, technical, or material support: Aboulafia, Epstein, Figueroa.

Supervision: Sommers, Figueroa.

Conflict of Interest Disclosures: Dr McIntyre reported grants from the Commonwealth Fund and Episcopal Health Foundation during the conduct of the study as well as grants from JPAL North America, the National Institute on Minority Health and Health Disparities, and the National Institute for Health Care Management Foundation outside the submitted work. Dr Sommers reported grants from the Commonwealth Fund during the conduct of the study as well as grants from the Episcopal Health Foundation, employment with the US Department of Health and Human Services from January 2021 to January 2023, and personal fees from Massachusetts Psychiatric Society outside the submitted work. Ms Aboulafia reported grants from theT32HS000055 trainee program of the Agency for Healthcare Research and Quality during the conduct of the study. Drs Orav and Epstein reported grants from the Commonwealth Fund during the conduct of the study. Dr Figueroa reported grants from the Commonwealth Fund and Episcopal Health Foundation during the conduct of the study as well as grants from the National Institutes of Health, Arnold Ventures, Robert Wood Johnson Foundation, and US Department of Veterans Affairs and personal fees from Humana Inc, Inter-American Development Bank, and Project Hope (Health Affairs) outside the submitted work. No other disclosures were reported.

Funding/Support: This study received funding from the Commonwealth Fund and Episcopal Health Foundation.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

Meeting Presentation: This study was presented at the AcademyHealth 2024 Annual Research Meeting; June 29, 2024; Baltimore, Maryland.

• Open access
• Published: 06 July 2024

The edutainment program on knowledge, perception, and uptake of cervical cancer screening among Muslim women in Southern Thailand: a quasi experimental study

• Tassanapan Weschasat 1 ,
• Nuttawut Wetchasat 3 &
• Montakarn Chuemchit 1 , 2  

BMC Public Health volume  24 , Article number:  1803 ( 2024 ) Cite this article

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Introduction

Cervical cancer is a significant global health concern and is the third most common cancer in women. Owing to their religious beliefs, Muslim women in Thailand are less likely to be screened for cervical cancer.

This study aimed to explore how a Health Belief Model (HBM) (HBM = Health Belief Model)-Based Edutainment Program affects the knowledge, perception, and uptake of cervical cancer screening among Muslim women in Thailand.

A quasi-experimental study was conducted in two rural districts of Southern Thailand with 83 Muslim women (intervention = 42, control = 41). The assessment was conducted through face-to-face interviews at baseline, post-intervention, and at 3-month follow-up. The intervention included four sessions involving video clips, folk songs, and short films. Data analysis was performed using repeated-measures ANOVA (ANOVA = Analysis of Variance) at a significance level of 0.05.

There were significant differences in the mean score of knowledge and perception between the intervention and control groups post-intervention and at 3-month follow-up ( p  < 0.001). The mean scores of knowledge and perception in the intervention group significantly increased post-intervention and at 3-month follow-up ( p  < 0.001). The uptake of cervical cancer screening tests in the intervention group was approximately twice as high as that in the control group (90.47% vs. 51.21%).

The findings revealed that the Edutainment Program could improve the knowledge, perception, and uptake of cervical cancer screening among Muslim women in Thailand. In future studies, the intervention suggests testing different population groups to improve access to primary care for everyone.

Peer Review reports

Cervical cancer is a significant public health issue that endangers women’s health and well-being worldwide [ 1 ]. Globally, 2,784 million women over 15 years of age are at a risk of developing cervical cancer. Annually, 569,847 women are diagnosed with the disease and 311,365 women die from cervical cancer [ 2 ]. Eighty-five percent of cervical cancer cases occur in developing countries and account for 13% of all cancer cases in females. With 20 deaths per 100,000 people, Asia has the highest mortality rate from cervical cancer [ 3 ]. There were 315,232 new cases of cervical cancer in Asia, of which 64% were in women aged 40–64 years. In this age group, 97,610 patients have died [ 4 ]. Mongolia, Indonesia, Maldives, Nepal, and Brunei are the five countries with the highest incidence rates ranging from 20.6 to 23.5 per 100,000 individuals. The incidence rates of cervical cancer in these five countries have some cases that are partly caused by the Human Papilloma Virus (HPV Footnote 1 ). Southeast Asia ranks sixth among all subregions worldwide in terms of cervical cancer mortality. Thailand ranks eighth in Asia, with an incidence rate of cervical cancer cases attributable to HPV of 16.2 per 100,000 people [ 5 ]. Fortunately, cervical cancer can be prevented and treated, and early detection has reduced morbidity and mortality rates globally [ 6 ]. Papanicolaou (Pap) smear is an efficient, affordable, and effective method for examining the uterine cervix for cytological abnormalities. The incidence and mortality of invasive cancer can be reduced through screening programs [ 7 , 8 ].

In Thailand, the Ministry of Public Health has been promoting the Pap smear test among women aged 30–60 years, with a regular follow-up screening interval of five years [ 9 ]. The Department of Medical Services set a target of 80% for screening and early detection among women aged 30–60 years in Surat Thani, a province in Southern Thailand. However, from 2015 to 2019, the coverage of the Pap smear test was only 47.89%. [ 10 ]. In five districts of Mueang Surat Thani, Samui, Chaiya, Tha Chana, and Ban Na Doem, the coverage of the Pap smear test was < 35%. Considering the population's religion, only 17% Muslim women had undergone the screening [ 10 , 11 ].

According to a literature review, cultural beliefs, religion, reproductive history, risk behaviors, attitudes, and sociocultural norms affect Muslim women's access to services and information related to cervical screening. In addition, Muslim women experience shame during screenings, fear of losing their traditional roles as women, fear pain and infection, lack knowledge, and find screenings expensive and inaccessible [ 6 , 7 , 8 , 12 ]. Therefore, Muslim women are at risk of missing cervical cancer screenings [ 8 , 11 ]. The absence of screening results in late-stage diagnosis increases treatment burden and mortality [ 13 , 14 , 15 ]. Since Islam is a popular religion in Southern Thailand, it suggests that religion may be a factor in these screening discrepancies [ 16 ]. Faith, beliefs, and cultural influences can impact health behaviors, including involvement in screening initiatives. Different communities may hold specific cultural beliefs that influence their approach to screening practices. The Islamic faith may influence health behaviors related to cervical cancer screening due to beliefs in the importance of modesty and self-respect for women. These beliefs could lead them to refrain from or be hesitant to participate in screenings, which may be perceived as intrusive due to their emphasis on privacy and personal dignity [ 12 , 17 , 18 ]. The disparities in cervical cancer screening among Muslim women may be due to their modesty [ 18 , 19 , 20 ].

There are many different factors that influence cervical cancer screening, and existing interventions have not fully addressed the barriers experienced by Muslim women during screening, which contributes to the ongoing disparities in cervical cancer screening among Thai Muslim women, particularly in the Surat Thani Province. Therefore, this study aimed to investigate how edutainment affects the uptake of cervical cancer screening among Thai Muslim women in the Surat Thani Province. The intervention program was developed using t-Based Edutainment Program with video clips, folk songs, and short films. These findings can increase the knowledge, perception, and uptake of cervical cancer screening among Thai Muslim women and encourage healthcare providers to apply the edutainment approach when promoting cervical cancer screening tests to the target population.

Materials and methods

Study design and participants.

This study applied a quasi-experimental design and was conducted in the rural areas of Southern Thailand between May and November 2021. This study was approved by the Ethics Review Committee for Research Involving Human Research Subjects, Health Science Group, Chulalongkorn University (158.3/63). Written informed consent was obtained from all participants involved in the study.

The inclusion criteria were Muslim women who had lived in Surat Thani province for more than a year, aged between 30–60 years, had never undergone a cervical cancer screening test, had been married or cohabiting, had access to healthcare services, could undergo a cervical cancer screening test, could communicate in the Thai language using the local dialect, and were willing to participate in the study. Muslim women who underwent hysterectomy with cervix removal and pregnant women were excluded.

Sampling technique and sample size

The participants (Fig. 1 ) were selected using a two-stage random selection technique. In the first step, two of 19 districts in Surat Thani Province with the lowest Pap smear test coverage were purposively selected. Using simple random sampling, Muslim women from Mueang Surat Thani district were assigned to the intervention group, while Muslim women from Chaiya district were assigned to the control group. In the second step, the researcher checked household records accessible to local health centers to identify and enroll eligible Muslim women. Simple random sampling was used to select 43 Muslim women from each group who had participated voluntarily and had never undergone a Pap smear test before the study.

Consort diagram of the participants

The sample size was calculated by considering the assumptions of 90% statistical power, 5% significance level (two-sided alpha), proportions (P1 = 0.92, P2 = 0.65) from a previous study that investigated "The effects of a motivated teaching program program on perception and cervical cancer screening rate among rural Thai women."[ 21 ], and 20% expected loss to follow-up. The total sample size was 86 participants from the calculation, with 43 participants for each group. However, 3 participants dropped out during the follow-up period, and only 83 participants (intervention = 42, control = 41) completed the study.

Intervention

The participants were divided into two groups: Muslim women from the Mueang Surat Thani district participated in the Edutainment Program of the intervention group, and Muslim women from the Chaiya district participated in the standard care of the control group. The Edutainment Program simultaneously provides information for education and entertainment. The program was based on the HBM theory to improve the knowledge and perception of cervical cancer screening and change the behavior of undergoing cervical cancer screening among Muslim women in the intervention group. The program was designed as a 4-week intervention with one session per week for 60 min. The Edutainment Program for Muslim audiences was developed using four components: video clips, folk songs, short films, and a reminder program. We developed a script for the short film and lyrics for the folk song based on the HBM, which included perceived susceptibility, severity, benefits, and barriers. Additionally, a reminder program for the intervention group using folk songs was broadcasted to the community every morning and evening and After the intervention 4 week, the research team conducted a follow-up program by providing information directly to the participants in their homes in their native language. Table 1 outlines the specifics of the Edutainment Program.

The participants in the control group did not receive any intervention apart from standard care, which included general knowledge of cervical cancer and information about cervical cancer screening from healthcare providers. The validity of the tool was assessed using a content validity test and content validity index (CVI). The intervention program was presented to three experts—a health education expert from College of public health sciences Chulalongkorn University, an epidemiology expert from College of public health sciences Chulalongkorn University and an Obstetrician-gynecologist from Surat Thani Hospital. They were asked to provide feedback based on the study objectives and the relevance of the content. Based on the feedback received from the experts, further modifications were made to the intervention program. This resulted in a content validity test score of 0.87 and a content validity index of 0.79. To ensure the reliability of the tool, and each construct had internal consistency reliability with Cronbach’s alpha of 0.71 it was administered to 30 Muslim women from the study population who matched the demographic variables of the sample group. Feedback was collected from all program participants through interviews prepared by the Reseacher team. The feedback from the program participants was carefully reviewed and used to enhance the content, increase engagement, and modify teaching methods to maximize effectiveness for the program participants.

The participants completed a semi-structured questionnaire at baseline, post-intervention, and at 3-month follow-up through face-to-face interviews. The questionnaire, which was administered by the researcher, was written in Thai. The knowledge and perception questions were adapted from constructs used in similar studies. Shojaeizadeh et al. (2011) investigated "The Effect of an Educational Program on Increasing Cervical Cancer Screening Behavior among Women in Iran Applying the Health Belief Model," while Maneechot (2017) examined "The effects of a motivated teaching program on perception and cervical cancer screening rate among rural Thai women" [ 21 , 23 ].

After holding research team meetings, and validity and reliability measurement, final questionnaire combination of was compiled and used. The knowledge questions had internal consistency reliability with a Cronbach’s alpha of 0.85 and consisted of 15 items (score range 0 – 15), with one score for each correct response. The perception questions based on the HBM constructs consisted of 15 items which included perceived susceptibility (4 items, score range 4—20), perceived severity (3 items, score range 3 – 15), perceived benefits (5 items, score range 5 – 25), and perceived barriers (3 items, score range 3—15) on five-point Likert scale (totally agree = 5, agree = 4, undecided = 3, disagree = 2, strongly disagree = 1), and each construct had internal consistency reliability with Cronbach’s alpha of 0.71, 0.71, 0.85, and 0.86, respectively. Uptake of the cervical cancer screening test was a binary outcome, in which the participants were categorized as having undergone cervical cancer screening at the time of assessment.

Statistical analysis

Data were analyzed using the statistical package for social sciences (SPSS) (version 22.0; IBM Corp., Armonk, NY, USA) at a significance level of 0.05. Descriptive statistics such as frequency, percentage, mean, and standard deviation were used to summarize the data. The chi-square test of independence (or Fisher’s exact test) for categorical data and the independent sample t-test for continuous data were used to compare baseline characteristics between groups. Repeated-measures analysis of variance (ANOVA) was used to analyze the effect of the Edutainment Program on knowledge and perception based on the HBM constructs among Muslim women between and within groups at baseline, post-intervention, and at 3-month follow-up.

Table 2 summarizes the sociodemographic characteristics of participants by study group. Among the 83 Muslim women, more than one-third had a secondary school level of education (38.55%), followed by primary school level (26.51%). Most participants in this study (93.98%) were married. Over one-third of Muslim women were self-employed (37.35%) and another one-third were housewives (34.94%). Their average monthly income was around 5,000–8,000 baht, and most (84.34%) received universal health insurance coverage. The reported age at first delivery was between 21–25 years (34.94%), followed by ≤ 20 years (32.53%). Majority had two deliveries (38.96%), with two live children (42.86%). In addition, 7.23% of the women reported having no children because of abortion. Most participants received information about cervical cancer through television (20.48%); however, more than half (51.81%) did not receive any information. The baseline characteristics were similar between the two groups.

Table 3 presents the results of the repeated-measures ANOVA to analyze the effect of the Edutainment Program on the knowledge of Muslim women between and within groups. There was a statistically significant difference between the intervention and control groups ( p  < 0.001). Within-subjects analysis revealed that the Edutainment Program resulted in significant changes in the mean knowledge of cervical cancer over the three time points ( p  < 0.001). The post-hoc pairwise comparison using Bonferroni correction indicated statistically significant differences between the intervention and control groups post-intervention and at 3-month follow-up ( p  < 0.001).

Table 4 describes the results of the repeated measures ANOVA analyzing the effect of the Edutainment Program on perceptions based on the HBM constructs of Muslim women between and within groups. There was a statistically significant difference between the intervention and control groups ( p  < 0.001). The within-subjects analysis showed that the Edutainment Program resulted in significant changes in mean perception based on the HBM constructs regarding cervical cancer screening over the three time points ( p  < 0.001). The post-hoc pairwise comparison using Bonferroni correction indicated statistically significant differences between the intervention and control groups post-intervention and at 3-month follow-up ( p  < 0.001).

Table 5 shows the percentage uptake of cervical cancer screening tests between the intervention and control groups at the three time points. At baseline, there was no difference in the percentage of cervical cancer screening tests performed between the intervention and control groups. The percentage of cervical cancer screening tests in the intervention group increased after implementation of the intervention program. The intervention group reported 90.47% of cervical cancer screening tests, which was nearly twice that of the control group (51.21%).

The Edutainment Program aimed to improve the knowledge of cervical cancer and perceptions based on the HBM constructs about cervical cancer screening among Muslim women in Thailand. This study demonstrated that the Edutainment Program was successful in improving knowledge of cervical cancer. There were differences in knowledge scores before and after the intervention program. In our Edutainment Program, Muslim women may be encouraged to learn more about cervical cancer and the importance of cervical cancer screening tests. The Edutainment Program comprised watching video clips, listening to folk songs, and watching short films. The researcher developed each component of the program based on the culture and traditions of Muslims and South Asians. After the intervention sessions, the research team implemented a follow-up reminder program by personally delivering information to the participants in their homes using their native language. This is similar to house visits conducted by public health workers in other projects [ 24 , 25 ]. This assists in connecting with the participants and motivates them to respond to any questions they may have regarding cervical cancer. These findings are consistent with those of a previous study that involved women in Malaysia and used educational talks, video displays, and experience-sharing sessions and reported that the results obtained by the actions of public health workers and multimedia were comparable [ 26 ]. Furthermore, an educational intervention that included lectures, discussions, videos, and leaflets was employed in a study on women in Ghana. In that study, health education was provided in churches, and it was found that health education interventions were critical in improving women’s knowledge of cervical cancer [ 27 ]. This is consistent with a previous study revealing that educational interventions improved the knowledge of women regarding cervical cancer in the experimental group [ 28 , 29 ]. Additionally, a randomized community trial in Malaysia found that educational talks, video shows, and experience-sharing sessions significantly increased women’s knowledge in the intervention group [ 26 ].

The findings revealed that perceptions based on the HBM constructs changed over the three time periods in the intervention group. This demonstrates how duration over two months affects perception. Based on our program, the perception of the participants increased after talking with the researcher in the local language, which encouraged Muslim women to easily understand the information. They learned about cervical cancer by watching a video of the Edutainment Program, which simulated a discussion on cervical cancer between Muslim women and physicians. This tool aims to show that doctor-patient interaction remains uninterrupted. The main components of the folk songs in our Edutainment Program were launched when the participants performed routine activities, such as praying. Muslims developed the folk songs of the Edutainment Program using the melodies of Muslim folk songs. The short film of the Edutainment Program was designed based on the construct of perception in the HBM. Some studies found that perceived susceptibility is low among women in intervention groups [ 30 ]. A study of Saudi women reported that they perceived themselves as having low susceptibility to cervical cancer [ 31 ]. The timing of the intervention affected participants' perceptions of how cervical cancer would adversely affect their health. One of the key achievements in stimulating the participants’ perceptions was the researcher's on-site face-to-face action. A previous study found that receiving advice from healthcare providers was a common facilitator stimulating participants’ perceptions [ 32 ]. However, our findings differ from those of prior studies, which indicated no statistically significant differences in perceived susceptibility scores between the pre-and post-tests [ 27 ]. This difference can be explained by the implementation of the Edutainment Program and number of follow-up visits. This is similar to the findings of a systematic review of women in Southeast Asia, which found that embarrassment was one of the main barriers to cervical cancer screening test [ 32 , 33 ]. Religious concerns were also a main barrier to the perception of women undergoing cervical cancer screening in this study [ 34 , 35 , 36 ]. This finding was supported by previous studies on breast and cervical cancer which reported that culture and values may have an impact on how HBM constructs affect breast and cervical cancer screening [ 37 , 38 , 39 ]. Although the study provided evidence for the effectiveness of the edutainment intervention, there were limitations such as the potential influence of other sources of information on both the intervention and control groups. Nonetheless, the HBM usage was a strength of this study, as it enabled the assessment of attitudes and behavior, and the Edutainment Program was beneficial in encouraging healthy behaviors among rural and underserved women.

Limitation and recommendations

This study had three limitations. First, the study areas of the intervention and control groups were rural. Because of the differences in lifestyle, sociodemographic, and economic conditions between urban and rural areas, generalization of the findings is not possible. Second, it could be applied to Muslim women in Southern Thailand since the study employed an intervention using the local language. Finally, participants completed a 4-week Edutainment Program and a 3-month follow-up. This study program was only of short duration; future studies should adopt the program with a long follow-up period (six months) after it was completed to assess the sustainability of the program.

Availability of data and materials

Data for this study were extracted from a Ph.D. dissertation at the College of public health sciences Chulalongkorn University All data generated during and/or analyzed.

during the study are available by the correspondent author on reasonable.

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Enyan NIE, et al. Correlates of cervical cancer screening participation, intention and self-efficacy among Muslim women in southern Ghana. BMC Womens Health. 2022;22(1):225.

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Acknowledgements

The authors thank all the participants who willingly participated in this study. We would especially like to thank the head of the provincial health office and the head of the primary health care unit in the Surat Thani province of Southern Thailand for permitting us to conduct the Edutainment Program.

This study was supported by the 90th Anniversary of Chulalongkorn University Fund (Ratchadaphiseksomphot Endowment Fund).

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Weschasat, T., Wetchasat, N. & Chuemchit, M. The edutainment program on knowledge, perception, and uptake of cervical cancer screening among Muslim women in Southern Thailand: a quasi experimental study. BMC Public Health 24 , 1803 (2024). https://doi.org/10.1186/s12889-024-19287-y

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This literature review describes findings from studies on various employment and training interventions to 1) assist individuals in recovery, 2) provide assistance to employers preventing opioid use disorder and creating a recovery-friendly workplace, and 3) develop the health care workforce to address the opioid crisis. The review was developed as part of an implementation evaluation of six Dislocated Worker Demonstration Grants to address the National Health Emergency (NHE) of the opioid crisis. Products form the study also include a resource guide, final report, and four short briefs on promising strategies.

As this review notes, the evidence base for employment interventions specifically aimed at or tested with people with opioid use disorder is limited and, that, while some of the approaches have been rigorously tested, others have not yet been evaluated but are seen as potentially promising practices. The research reviewed covers such approaches as:

• Intensive case management, as found in various models, such as the individual placement and support (IPS) model, a counseling model based on the interpersonal cognitive problem solving (ICPS) method; and a strategy based on the customized employment support (CES) vocational model;
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The literature notes that, overall, the research on employment-related interventions for people with opioid use disorder is still in its infancy, and for that reason, opportunities for building evidence should be capitalized upon by any organization providing services to address it, and in so doing, lay the groundwork for more rigorous studies.

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Predictor of anemia among pregnant women attending antenatal clinics at Hiwot Fana Comprehensive Specialized Hospital, Eastern Ethiopia: a case-control study

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Tadesse Dufera, Merga Dheresa, Tariku Dingeta, Mezgebu Legesse, Sinetibeb Mesfin, Bikila Balis, Tegenu Balcha, Predictor of anemia among pregnant women attending antenatal clinics at Hiwot Fana Comprehensive Specialized Hospital, Eastern Ethiopia: a case-control study, International Health , Volume 16, Issue 4, July 2024, Pages 438–445, https://doi.org/10.1093/inthealth/ihad118

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Anemia during pregnancy is a public health problem and is related to negative birth outcomes, especially in developing countries. The main aim of this study was to assess predictors of anemia among pregnant women attending antenatal clinics at Hiwot Fana Comprehensive Specialized University Hospital, Eastern Ethiopia.

Unmatched case-control study design was employed among 352 individuals. A face-to-face interview was used to gather data, and each pregnant woman's antenatal care follow-up record cards were reviewed in addition to the interview. EpiData version 3.1 and IBM SPSS version 26 was used for data entry and analysis, respectively. Bivariable and multivariable analyses were conducted to identify predictors of anemia, a p-value of <0.05 was considered a statistically significant association.

The common determinants for anemia in pregnant mothers were: rural residency (AOR = 2.25, 95% CI: 1.14–4.8), no formal education (AOR = 4.4, 95% CI: 1.94–9.9), inter-pregnancy interval (AOR = 2.7, 95% CI: 1.24–5.8), and mid-upper arm circumference (AOR = 5.0, 95% CI: 2.0–12.7).

In this study, the identified determinant factors for anemia were: rural residency, maternal educational status, inter-pregnancy-interval, and mid-upper arm circumference. Therefore, providing health education and promotion for pregnant women regarding anemia by focusing on rural residents and counseling to lengthen their birth spacing is an important task. Moreover, counseling on taking iron supplementation as suggested and consuming a diet rich in iron during antenatal care will be recommended.

Anemia during pregnancy is defined by the WHO as hemoglobin (Hgb) concentrations of less than 11 g/dl for the first and third trimesters and 10.5 g/dl for the second trimester. 1 Anemia during pregnancy is a public health problem and is related to negative birth outcomes, especially in developing countries. 2 Anemia can be caused by a variety of factors during pregnancy; it is caused by deficiencies in iron, folate, vitamin B12, and vitamin A, as well as intestinal parasite infections, malaria, and chronic sickness. 3 , 4 Fetal anemia, low birth weight, preterm delivery, intrauterine growth restriction, and perinatal mortality were all effects of anemia on both pregnant mothers and their newborns. 5 , 6 Anemia during pregnancy is a significant factor in the morbidity and death of pregnant women and newborns in underdeveloped nations. 5 , 7

According to the WHO, 32.4 million (38.2%) of women worldwide developed anemia during their pregnancy, with 48% in Southeast Asia and 46.3% in Africa. 8 Nearly 510 000 maternal deaths are reported each year around the world as a result of childbirth or early postpartum complications. Anemia is responsible for around 20% of maternal deaths, the majority of which occur in underdeveloped nations. 9 , 10 The overall prevalence of anemia was 43.3% in sub-Saharan African countries. 11 In Ethiopia, a pooled prevalence of the systematic review showed that 31.7% of women developed anemia during their pregnancy period; according to this systematic review report the lowest prevalence was observed in the Amahara region (15.9%) and the highest was in the Somali region (56.8%). 12 Looking at regional variances, the Somali region had the greatest frequency of anemia (60%) followed by the Afar region (45%), and Addis Ababa had the lowest (16.3%). 13 According to the Ethiopia Demographic and Health Survey 2016, the problem affected 29% of people, and 37.9% of pregnant women in the study area. 13 , 14

According to previous findings, undernutrition, low meal frequency, multivitamin deficiency, and a lack of iron folate supplementation during pregnancy are all variables that significantly contribute to maternal anemia. 3 , 10 , 15 , 16 Mothers with increased gestational age, high parity, and gravidity also have a greater risk of anemia in pregnancy. 7 , 17 , 18 The socioeconomic factors of anemia include rural residency, illiteracy, a large family size, and poor economic status. 19–22

To address pregnant women's micronutrient insufficiency, the Federal Ministry of Health developed a national nutrition policy. It also set up a system for providing integrated and regular nutritional examinations and interventions such as deworming, folic acid, and iron supplementation. 23 , 24 Despite governments’ and stakeholders’ involvement, the anemia problem remains unsolved in Ethiopia, specifically in the study area, and still requires attention. Several studies on the prevalence of anemia in Ethiopia have been carried out, but there is still a gap in identifying the determinant factors and updating the information. In addition to this, there is no documented data on determinants of anemia during pregnancy in the study area. Therefore, this study aimed to assess the determinants of anemia during pregnancy among women attending antenatal clinics at Hiwot Fana Comprehensive Specialized Hospital (HFCSH).

Study setting and period

HFCSH is located in Harar town, 526 km to the east of Addis Ababa. HFCSH functions as the only referral hospital for the entire eastern part of Ethiopia, Dire Dawa City, the Somali region, and the Harari regional state. It is affiliated with the College of Health and Medical Sciences, Haramaya University, Ethiopia. Currently, the hospital has about 201 beds and 12 case teams to provide referral inpatient and outpatient services to residents of the Harari region and nearby regions. The study was carried out from 23 May 2020 to 23 August 2020.

Study design and population

An unmatched case-control study was undertaken at the hospital. The study participants were all pregnant mothers receiving antenatal care follow-up at HFCSH. Cases were all pregnant mothers who were attending antenatal care at HFCSH whose Hgb level was <11 g/dl for first and third trimester pregnancy while the Hgb level was <10.5 g/dl for second trimester pregnancy. Controls were all pregnant women who were attending antenatal care at HFCSH whose Hgb level was ≥11 g/dl for first and third trimester pregnancy, as well as ≥10.5 g/dl for second trimester pregnancy. All pregnant women who came for antenatal contact at HFCSH were included in the study. Seriously ill pregnant mothers, who had been on anti-helminthic drugs within the past two weeks, and those who had acute and/or chronic disease-causing anemia were excluded from the study.

Sample size determination and sampling procedure

To estimate the sample size, a double population proportion formula was employed using Epi Info version 7.2.0.1, with a 95% CI, 80% power, and control-to-case ratio of 2:1. Based on this, the husband's educational status was taken as the main exposure variable with a proportion of 27.3% among cases and 13.5% among controls with OR = 2.4. 25 Considering a 10% non-response rate, the final sample size was 352 (118 cases and 234 controls). The selection of study participants was made consequently until the required sample size was achieved.

Data collection instruments and procedures

Information was collected by using a structured questionnaire and reviewing each pregnant woman's antenatal care follow-up records. The questionnaire was modified to fit the local context after being adapted from prior research conducted in Ethiopia and abroad. 25–28 It consisted of sociodemographic characteristics, knowledge-related, health-related, and maternal dietary status, which were developed in an English-language version and translated into the local language (Afan Oromo and Amharic) before information gathering. It was then translated back into English to maintain consistency.

Measurements

The WHO definition of anemia in pregnancy was utilized to estimate the hemoglobin cutoff value, pregnant women with hemoglobin levels equal to or above 11 g/dl during their antenatal care services were chosen as controls (non-anemic), while those with Hgb levels less than 11 g/dl were chosen as cases (anemic). 1 Hemoglobin measurement, malaria attack, and stool examination were taken from maternal antenatal care follow-up record charts. The dietary diversity score was determined using a single 24-h memory, and all liquids and meals taken the day before the research were divided into 10 food groups. Consuming 5 or more out of 10 food groups within 24 h was considered as high food diversity while consuming less than 5 food groups within 24 h was taken as low food diversity. 29 Besides this, the mid-upper arm circumference (MUAC) was examined using a WHO measuring tape to evaluate malnutrition in pregnant women; a woman was classified as undernourished if her MUAC was less than 23 cm and well nourished if it was greater than or equal to 23 cm. 30 In this study, cases were assigned ‘1’ and controls were ‘0’.

Data quality control

Before the actual data gathering, the surveys were pre-tested using 5% of the calculated sample size at Jugal Hospital, and any necessary adjustments were implemented accordingly. During the information-gathering period, two BSc midwives were hired as data collectors and one MSc nurse as supervisor. Training was provided for the data collectors and supervisors on the goal of the study, the clarity of the tools, how to maintain the privacy of the information, and the quality of the data. Intensive supervision was undertaken by the principal investigator, as well as supervisors. Again information taken from medical record cards was cross-checked with participants’ clinical results registered in the laboratory registration book to check their consistency and quality. The supervisors checked the collected data for completeness, accuracy, and consistency.

Data analysis

Collected information was cleaned, coded, and entered into EpiData version 4.6. SPSS statistical software version 26 was used for analysis. To determine the frequencies, a measure of central tendency, and the variability of the variables used in this study, descriptive statistics were used. Bivariable and multivariable logistic regression analysis was used to identify the association between each independent and dependent variable. Utilizing the variance inflation factor and standard error, multicollinearity was examined to see whether the associated independent variables were correlated. Hosmer-Lemeshow goodness-of-fit and the omnibus test were used to assess the fattiness of the models. To adjust for all potential confounders, a variable with a p-value of 0.25 at 95% CI in the bivariable analysis was added to the multivariable logistic regression analysis. The strength and direction of the association between the independent and dependent variables were then assessed using AOR with a 95% CI and p-values in the multivariable logistic regression analysis. A p-value of 0.05 was then used as the cutoff value to identify the association as statistically significant.

Sociodemographic characteristics of study participants

In total, 352 participants (118 cases and 234 controls) took part in the study with a 100% return rate. Participants’ ages ranged from 18 to 40 years with most aged between 24 and 29 (40.1%) years. Around 230 (98.3%) controls and 110 (93.2%) cases were married with 73.3% controls and 40 (33.3%) cases residing in urban areas. Regarding religion, around 116 (49.6%) controls and 92 (78%) cases were Muslim and 39 (16.7%) controls and 57 (48.3%) cases had no formal education (Table  1 ).

Sociodemographic characteristics of pregnant women who visited ANCs at Hiwot Fana Specialized University Hospital Eastern Ethiopia, 2020

Note : Others: (waaqeffata and catholic), others*: (merchant, students, farmer, and daily worker), others**; (merchant, student, and daily worker).

Obstetric-related characteristics

Among the pregnant women who were receiving antenatal care at the hospital, 24.4% of controls and 45% of cases were gravida four and above. The majority of the participants, 65.4% of controls and 51.7% of cases had a birth gap of more than 2 years. Furthermore, 7 (3%) controls and 17 (14.4%) cases had a history of abortion (Table  2 ).

Obstetric characteristics of pregnant women who visited ANCs atn Hiwot Fana Specialized University Hospital, Eastern Ethiopia in 2022

Parasitic infection-related characteristics

The majority of the cases (89%), and almost all of the controls (96.7%), had not had fever in the previous three months. Among antenatal care attendants, 5 (2.1%) controls and 8 (6.8%) cases had had a fever in the last 48 h. Almost three-quarters (72.6%) of cases and 78.8% of controls did not use insecticidal bed net (ITN). Moreover, 5 individuals from controls and 7 from cases had parasitic infections. Among the participants, 21 cases and 10 controls used antimalarial drugs. About 3% of controls and 11% of cases had a history of past medical illness (Table  3 ).

Health-related characteristics of pregnant women who visited ANCs at Hiwot Fana Specialized University Hospital, Eastern Ethiopia in 2020

Dietary-related characteristics of the respondent

Nearly two-thirds of controls, 167 (71.4%), and 83 (70.4%) cases consumed foods three or more times a day. About 94 (40.2%) controls and 26 (22%) cases consumed iron-rich foods. The majority of participants, 227 (97.1%) controls and 104 (88.2%) cases, took tea or coffee daily. The majority of pregnant women who received antenatal care, 97 (41.5%) controls and 51 (43.2%) cases, were taking iron supplements. About 28 (23.7%) cases and 46 (19.7%) controls were consuming vitamin A-rich foods (Table  4 ).

Dietary-related characteristics of pregnant women who visited ANCs at Hiwot Fana Specialized University Hospital, Eastern Ethiopia in 2020

Clinical extract

Regarding the MUAC, out of 352 study participants, 10.3% of controls and 26.3% of cases had a MUAC of less than 23 cm, while 89.7% of controls and 73.7% of cases had a MUAC equal to or greater than 23 cm, respectively. Nearly three-quarters (74.6%) of cases and 214 (91.5%) controls had no intestinal parasite but 3.0% of controls and 14.4% of cases had intestinal parasites. About 5.5% of controls and 11% of cases had signs of bacterial infection.

Determinants of anemia during pregnancy

To identify independent predictors of anemia, multivariable binary logistic regression analysis was carried out for variables that were candidates at a p-value of less than 0.25 in bivariable analysis. Variables such as husband’s educational status, residency, maternal educational status, use of iron-rich foods, gravidity, birth interval, use of leafy vegetables, iron supplementation, and MUAC were transferred to multivariable binary logistic analysis from the bivariable analysis. Finally, variables such as residency, maternal educational status, inter-pregnancy interval, and MUAC were found to be independent predictors of anemia during pregnancy at a p-value of <0.05 in multivariable analysis.

This study indicated that anemia was nearly three times higher among rural pregnant women than their urban counterparts (AOR = 2.94, 95% CI: 1.22, 7.1). The probability of getting anemia in pregnant mothers who had no formal education was 4.4 times higher compared with those who had received formal education (AOR = 4.4, 95% CI: 1.94–9.9). The odds of developing anemia among pregnant women whose birth interval was less than two years were nearly three times higher than women whose birth interval was greater than two years (AOR = 2.7, 95% CI: 1.24–5.8). According to this study, pregnant women whose MUAC measurement was <23 cm were five times more likely to be anemic compared with their counterparts (AOR = 5.0, 95% CI: 2.14–12.7) (Table  5 ).

The factors that contribute to the occurrence of anemia must be recognized in order to successfully prevent anemia during pregnancy. Thus, residency, maternal educational status, inter-pregnancy interval, awareness among pregnant women, and MUAC were the variables that were significant predictors of anemia.

In this study, residency was one of the predicting factors of anemia. Women who were living in rural areas were twice as likely to develop anemia compared with those who lived in urban areas. This finding was supported by a study conducted at Adigrat Hospital, northern Ethiopia, 31 Dera district, northwest Ethiopia, 32 Bisidimo Hospital, eastern Ethiopia, 10 Gilgel Gibe dam area, southwest Ethiopia, 33 and a study conducted in Uganda. 34 This might be due to pregnant women living in rural areas lacking information about increased nutritional consumption during pregnancy and having limited access to healthcare facilities, making them more exposed to anemia. 35

Bivariable and multivariable analysis predictor of anemia among pregnant women visiting ANCs at Hiwot Fana Specialized University Hospital, Eastern Ethiopia in 2020

AOR: adjusted odds ratio; COR: crude odds ratio; MUAC: mid-upper arm circumference.*p<0.05, **p<0.01, 1 = reference.

One of the key determinants of anemia in pregnant women was the mother's education level. Pregnant women without formal education had four times higher odds of getting anemia than pregnant women with formal education. This finding was supported by studies carried out in different parts of Ethiopia, West Gojjam Zone , 36 Benchi Maji Zone, 37 Woldia Town, 38 Yrga cheffe health facilities, 39 and Tanzania. 40 This might be because women with no formal education did not have sufficient access to information regarding the danger of anemia. Even if they have been advised to take iron tablets and other preventive measures such as consuming iron-rich meals, they may not do so. Furthermore, because education is linked to wealth, illiterate women may not be able to earn enough money to feed themselves during their pregnancy.

This study showed that pregnant women whose pregnancy interval was less than two years were nearly three times more likely to acquire anemia compared with their counterparts. This finding was consistent with studies carried out in North Ethiopia Shire town, 41 Arba Minch town, 42 Wollega University Hospital, 43 Bangladesh, 44 and India. 20 The possible explanation for this might be a short inert birth interval that has resulted in a decreased iron store, which may exacerbate the occurrence of anemia in pregnant women.

The likelihood of anemia was five times higher among pregnant women whose MUAC measurement was <23 cm compared with those whose MUAC measurement was >23 cm. The result of this study was strengthened by the study being conducted in the Oromia region, 45 Dera district, northwest Ethiopia, 32 Horo Guduru Welega, 46 West Ethiopia, and Gode town, eastern Ethiopia. 47 This might be because a MUAC measurement below 23 cm could be an indicator of malnutrition, which is the most common cause of anemia. Moreover, this could be connected to the deleterious impact that protein and other macronutrient deficiencies have on the bioavailability and storage of iron and other hematopoietic nutrients. As a result, the majority of micronutrient deficits are associated with protein-energy malnutrition; to prevent this, micronutrient supplementation is recommended as a routine intervention by the WHO and various local nutritional management guidelines. 48

Strengths and limitations of the study

This study utilized a combination of face-to-face interviews and chart review to avoid missing any important variables; the nature of the design helped to establish cause and effect relationships. However, recall and social desirability bias were a common limitation of this study.

In this study, the identified determinant factors of anemia were: rural residencies, maternal educational status, inter-pregnancy interval, and MUAC. Pregnant women’s awareness of anemia should be increased through strengthened health education and community mobilization on identified determinants of anemia by prioritizing rural women. Enhancing women's education, and increasing family planning accessibility to improve inter-pregnancy interval is mandatory to overcome the problem. Nutritional guidance should be given on consuming foods high in iron and taking iron supplements to prevent anemia in pregnant women. Finally, to reduce sequels of anemia during pregnancy we recommend further community-based studies to explore other risk factors of anemia in pregnancy.

TD, MD, TB, and TD were all involved in the research concept, design, data collection, analysis, and interpretation. TB, SM, ML, and BB drafted the manuscript, and all authors reviewed and contributed intellectual content. All authors have read and approved the final version of the manuscript.

We would like to thank Haramaya University, College of Health and Medical Sciences, School of Graduate Studies for allowing us to do this research. Moreover, we would like to thank the participants of this study, data collectors, and supervisors.

The authors did not receive any funding for the authorship or the publication of this paper.

The authors declare that they have no competing or potential conflicts of interest.

Ethical clearance was obtained from the Institutional Health Research Ethics Review Committee (IHRERC) of the College of Health and Medical Sciences, Haramaya University (Ref. No:128/2020). A permission letter was received from the management of the hospital. Informed written and signed consent was obtained from those who could read and write while fingerprint sign was obtained from those who could not read and write. The study was conducted according to the recommendations of the Declaration of Helsinki. Confidentiality was maintained by using anonymous codes, de-identified study participants’ identifiers, and keeping the data in a secure place.

All supplemental materials for this article are available from the corresponding authors based on reasonable request.

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