Search

Phenomenon: Improving the learning environment (LE), particularly for students underrepresented in medicine (URM), has become an important goal for institutions that provide undergraduate and graduate medical education. Until recently, research and intervention development have been limited by the lack of comprehensive theoretical frameworks. A multi-dimensional conceptual model of the medical school environment, developed by Gruppen and colleagues in 2019, provides a useful framework for guiding research and interventions in this area. Approach: Using Gruppen et al's model, this study investigated experiences of the LE from the perspectives of both URM and non-URM students at a medical school in New York City. In examining experiences of the organizational, social, and physical domains of the LE, we sought to explore the symbolic and experiential links across domains and identify concrete needs for improvement. Findings: Institutional structures and policies, features of the built environment, and social relationships that put learning first and generated a sense of community were highly valued. Although both URM and non-URM students shared many perceptions and experiences, URM students expressed heightened vulnerability to the experiences of devaluation and exclusion. Insights: All participants in the study greatly appreciated aspects of the LE that made them feel like valued members of the community. Medical schools should approach the task of improving the LE for URM students using a comprehensive, multi-dimensional approach. [ABSTRACT FROM AUTHOR]

Objectives: Optimally, cancer is diagnosed through periodic screening or detection of early symptoms in primary care settings. However, an estimated 23%–52% of gastrointestinal (GI) cancers are diagnosed in the emergency department (ED). Cancer diagnosed in the ED has been associated with worse clinical and patient‐reported outcomes even after adjustment for cancer stage. We sought to explore patients' accounts of patient and health care system factors related to their diagnosis in the ED and their lived experience of receiving a diagnosis in this setting. Methods: Patients with an ED visit during or within 30 days of their GI cancer diagnosis at an urban academic hospital serving a largely disadvantaged population were recruited. Interviews were coded in NVivo 12 and analyzed using a thematic analysis approach. Results: Patient‐reported factors associated with their experiences included denial and avoidance of symptoms, mistrust of the health system, and lack of cancer screening knowledge. Health care system factors included misdiagnosis and delayed access to specialty care or tests. Experiences receiving a cancer diagnosis in the ED were overwhelmingly negative. Conclusions: This study highlights the unmet needs in identifying and diagnosing patients who ultimately present to the ED for evaluation and eventual diagnosis of cancer. Our results shed light on several modifiable factors, including the need for increased public awareness of the asymptomatic nature of cancer and the importance of cancer screening. Additionally, health care systems modifications beyond the ED are needed to improve access to timely care when symptoms arise. [ABSTRACT FROM AUTHOR]

Background Depressive symptoms are prevalent among people who inject drugs (PWID) and people with hepatitis C virus (HCV). We examined changes in depressive symptoms among HCV-infected PWID following direct-acting antiviral treatments to evaluate whether these changes differed by history of depressive symptoms, substance use, or HCV treatment outcome. Methods We conducted a secondary analysis of the HERO Study (NCT02824640), a pragmatic randomized clinical trial among PWID, to test the effectiveness of HCV care models. Depressive symptoms (primary outcome) were measured using the Patient Health Questionnaire (PHQ-9) at baseline, end of treatment (EOT), and at follow-up 12 and 24 weeks after EOT. Sustained virologic response (SVR) was defined as undetectable HCV RNA at ≥12 weeks following EOT. Baseline drug use was defined as having a positive urine screening test for amphetamine, methamphetamine, benzodiazepine, cocaine, cannabis, opiate, or oxycodone. Results The sample (n = 498) was 72.3% male, 64.2% White, and on average 43.9 years old. In patients who achieved SVR (F(3432) = 4.58; P =.004) and those with drug use at baseline (F(3478) = 5.11; P <.01), PHQ-9 scores significantly declined over time, with scores lower at EOT and both follow-ups as compared with baseline. Mean PHQ-9 scores at EOT and follow-ups were significantly lower than at baseline, except for those with no depression or mild depression at baseline. Conclusions This study showed that HCV treatment in PWID is associated with sustained declines in depression up to 24 weeks post-treatment among those who achieve SVR and that drug use does not interfere with improvement in depressive symptoms. [ABSTRACT FROM AUTHOR]

Although interventions based on cognitive theories can reduce rates of unsafe sexual behavior in adolescents, effect sizes remain small. This study was a qualitative investigation of inner-city adolescents' intentions to use condoms following participation in an intensive safer sex program. In-depth interviews with 26 adolescents were analyzed using standard qualitative methods. Although participants reported strong intentions to use condoms, they described many exceptions to their intention. Condom use intentions were also trumped by the presence of alternative, often conflicting intentions. Typical barriers to condom use played a minor role compared to exceptions and competing intentions. Boys and girls differed in the ways exception to intention and alternate intentions interfered with condom use; these reflected gender roles and norms, which are often neglected in HIV/STD prevention programs. The authors conclude that the barrier model to explain non-condom use is incomplete and that the concept of intention itself may need more conceptual work.

The considerable risk of negative consequences of unprotected intercourse underscores a need to better understand how Latina adolescent girls acquire the skills to manage the risks associated with sexuality. The authors used in-depth qualitative interviews with mothers and their daughters to examine communication related to sexuality with the goal of understanding the sociocultural and family context of Latina adolescents sexual behavior and reproductive health care seeking. Mothers and daughters agree that sexual activity threatens girls health and future and that open communication about sexuality is highly valued but difficult to achieve. Communication content tends to focus on the threats of sexual activity, but process is important. Strategies of effective communicators include deliberate creation of an atmosphere of approachability and a flow of information from daughter to mother. (Contains 1 table.)

South Asian (SA) Americans have a high risk of metabolic and cardiovascular disease. Prevention efforts should start in childhood and should be culturally appropriate. We sought to understand the challenges and barriers that pediatricians face in providing care for SA children to inform professional education on culturally effective care. Qualitative interviews were conducted with a diverse sample (N = 17) of pediatricians. Challenges reported included feeding problems, inadequate physical activity, and mental health concerns. Communication barriers included parents' anxiety around feeding, influence of grandparents, stigma around mental health, and cultural communication gaps. Effective strategies included clear communication, a gradual approach, ensuring buy-in from grandparents, greater attention to family history, and improved cultural knowledge in pediatrician. Addressing feeding problems was the most mentioned challenge, which is especially concerning given the high chronic disease risk in SAs. Education on culturally appropriate strategies can equip pediatricians to effectively counsel SA families to address these risks. [ABSTRACT FROM AUTHOR]

Background: Direct-acting antiviral medications have the potential to eliminate the hepatitis C virus (HCV) epidemic among people who inject drugs; yet, suboptimal adherence remains a barrier. Directly observed treatment (DOT), an effective strategy for optimizing adherence, has been frequently implemented in opioid treatment programs but less commonly in community health settings due to the heavy burden of daily visits. An alternative is video-observed therapy (VOT), which uses mobile health technology to monitor adherence. VOT has not been widely studied among people who inject drugs with HCV. Objective: This qualitative study, part of a larger implementation evaluation, investigates stakeholder perceptions and experiences with VOT in Project HERO (Hepatitis C Real Outcomes), a multisite pragmatic trial testing treatment delivery models for people who inject drugs with HCV. Our goal was to understand the potential barriers and facilitators to the implementation of the VOT technology. Methods: Qualitative interviews were conducted with 27 Project HERO study staff and 7 patients. Interviews focused on perceptions and experiences with the VOT app and barriers and facilitators to implementation. Team meeting minutes over the first 2 years of the project were transcribed. A coding system was developed and applied to the data. We summarized thematic data and compared participant perceptions to generate a close understanding of the data. Results: Frequent barriers to VOT included mechanical failure, stolen or lost phones, and a steep learning curve for participants and study staff. In sites with older and less technically skilled participants, staff found it difficult to implement the VOT app. Research staff found that the routine monitoring of app use led to closer engagement with participants. This was both a benefit and a potential threat to the validity of this pragmatic trial. Patient participants reported mixed experiences. Conclusions: VOT may be a useful alternative to DOT for some patients, but it may not be feasible for all. Significant staff involvement may be required. [ABSTRACT FROM AUTHOR]

There has been little study of the content of bioethicists' communication during family meeting consultations about end of life care. In the literature, two roles for bioethicists are usually described: the 'consultant' role, in which bioethicists define and support ethical principles such as those enshrined in the 'rational choice' model; and the 'mediator' role, which focuses on the enhancement of communication in order to reduce conflict. In this study, we use observational data to explore how bioethicists support the practice of decision making during family meetings about end of life care. In a study conducted in the Bronx, New York, USA, researchers observed and recorded 24 decision-making meetings between hospital staff and family members of elderly patients identified as being in the last stages of illness, who were unable or unwilling to make the decision for themselves. Bioethics consultants were present during five of those meetings. Although bioethicists referred to the 'rational choice' decision-making hierarchy, we did not see the systematic exploration described in the literature. Rather, our data show that bioethicists tended to employ elements of the rational model at particular turning points in the decision-making process in order to achieve pragmatic goals. As mediators, bioethicists worked to create consensus between family and staff and provided invaluable sympathy and comfort to distressed family members. We also found evidence of a context-dependent approach to mediation, with bioethicists' contributions generally supporting staff views about end of life care. Bioethicists' called to consult on family meetings about end of life care do not appear to adhere to a strict interpretation of the official guidelines. In order to negotiate the difficult terrain of end of life decision making, our data show that bioethicists often add a third role, 'persuader', to official roles of 'consultant' and 'mediator'. Keywords: Bioethics; Bioethics consultation; Family decision making; End of life; Palliative care; USA

Members of ethnic minority groups are less likely than white middle class people to seek professional treatment for depression and other mental health problems. One explanation is that the former conceptualize depressive symptoms as social problems or emotional reactions to situations, while the latter are more apt to view depression as a disease requiring professional treatment. Though considerable evidence supports this hypothesis, it is rarely explored directly through cross-cultural comparisons. The present study compares conceptual models of depressive symptoms in two diverse cultural groups in New York City (USA): 36 South Asian (SA) immigrants and 37 European Americans (EA) were presented with a vignette describing depressive symptoms and participated in a semi-structured interview designed to elicit representational models of the symptoms. Results indicate pervasive differences in representational models across the two groups. SA participants identified the 'problem' in the vignette in largely social and moral terms. Suggestions for management and health seeking in this group emphasized self-management and lay referral strategies. EAs, by contrast, often proposed alternate, sometimes contradictory, explanatory models for the depressive symptoms. One model emphasized biological explanations ranging from 'hormonal imbalance' to 'neurological problem.' The second model resembled the 'situational stress' or 'life problem' model described by SAs. The implications of these findings, and directions for future research, are discussed. Keywords: Depression; Cultural differences; Illness representation; Conceptual models; USA

As medical treatment for AIDS has become more complex, the need for good palliative and end-of-life care has also increased for patients with advanced disease. Such care is often inadequate, especially among low-income, ethnic minority patients. The current study investigated physicians' experiences with caring for dying HIV patients in an underserved, inner city community in the Bronx, NY. The goals of the study included: (1) to investigate the barriers to effective end-of-life care for HIV patients; and (2) to examine physicians' experiences of role hindrance and frustration in caring for dying patients in the era of HAART. Qualitative, open-ended interviews were conducted with 16 physicians. Physicians identified two core, prescriptive myths shaping their care for patients with HIV. The 'Good Doctor Myth' equates good medical care with the delivery of efficacious biomedical care. The role of the physician is defined as technical curer, while the patient's role is limited to consultation and compliance. The 'Good Death Myth' envisions an ideal death which is acknowledged, organized, and pain free: the role of the physician is defined as that of comforter and supporter in the dying process. Role expectations associated with these myths were often disappointed. First, late-stage patients refused to adhere to treatment and were thus dying 'unnecessarily.' Second, patients often refused to acknowledge, accept, or plan for the end of life and as a result died painful, chaotic deaths. These realities presented intense psychological and practical challenges for providers. Adaptive coping included both behavioral and cognitive strategies. Successful adaptation resulted in 'positive engagement,' experienced by participants as a continuing sense of fascination, gratification, and joy. Less successful adaptation could result in detachment or anger. Participants believed that engagement had a powerful impact on patient care. Working with dying HIV patients in the post-HAART era of efficacious treatment challenges physician's cherished roles and values. Physicians adapt to the challenge through a variety of cognitive and behavioral strategies. The failure to adapt successfully has psychological consequences for providers that may impact patient care. Keywords: HIV; Palliative care; End-of-life care; The good death; Adherence

To ascertain how sleep health knowledge is translated to early care and education (ECE) programs, using a multi-component environmental scan. A website scan identified organizations' sleep content re: recommended practices, developmental effects, and "actionable" ratings (0–2). ECE staff surveys assessed preparedness, practices, and beliefs about addressing sleep health and sleep problems in ECE programs. Semi-structured interviews with stakeholders from the ECE, pediatric and sleep communities assessed awareness, priorities, and practices at their organizations. Of 15 websites scanned, half lacked sleep content on links to development, optimal duration, or scientific background. ECE staff (n = 31) were comfortable speaking to parents about healthy sleep, and with incorporating sleep education and guidance into ECE. Stakeholders (n = 15) rated healthy sleep as a high relevance, but lower priority issue. Within ECE settings stakeholders reported that knowledge about specific links to health and development was poor and that sleep health was often obscured by "safe sleep" issues. Their recommendations included: linking sleep health to "hot topics" such as obesity or preschool suspensions and expulsions, integrating it with the teaching of routines, and raising public awareness. Despite understanding that healthy sleep promotes school readiness, there is insufficiently specific, actionable information in ECE training, programs, or policies. Findings suggest a need for an awareness campaign with clear, actionable messaging, dissemination of turnkey materials, and integration with policy and professional training systems. – ClinicalTrials.Gov: NCT03556462 [ABSTRACT FROM AUTHOR]

Comparative effectiveness research trials in real-world settings may require participants to choose between preferred intervention options. A randomized clinical trial with parallel experimental and control arms is straightforward and regarded as a gold standard design, but by design it forces and anticipates the participants to comply with a randomly assigned intervention regardless of their preference. Therefore, the randomized clinical trial may impose impractical limitations when planning comparative effectiveness research trials. To accommodate participants' preference if they are expressed, and to maintain randomization, we propose an alternative design that allows participants' preference after randomization, which we call a "preference option randomized design (PORD)". In contrast to other preference designs, which ask whether or not participants consent to the assigned intervention after randomization, the crucial feature of preference option randomized design is its unique informed consent process before randomization. Specifically, the preference option randomized design consent process informs participants that they can opt out and switch to the other intervention only if after randomization they actively express the desire to do so. Participants who do not independently express explicit alternate preference or assent to the randomly assigned intervention are considered to not have an alternate preference. In sum, preference option randomized design intends to maximize retention, minimize possibility of forced assignment for any participants, and to maintain randomization by allowing participants with no or equal preference to represent random assignments. This design scheme enables to define five effects that are interconnected with each other through common design parameters-comparative, preference, selection, intent-to-treat, and overall/as-treated-to collectively guide decision making between interventions. Statistical power functions for testing all these effects are derived, and simulations verified the validity of the power functions under normal and binomial distributions. [ABSTRACT FROM AUTHOR]

South Asian immigrants are among the fastest growing immigrant groups in the United States. Children in low income South Asian families are at high risk for early childhood caries, a common disease with implications for child development and health in adult life. Culturally sensitive, user friendly intervention models are needed to engage Asian immigrant families regarding oral health risk. We conducted a pilot/feasibility study of SAPNA (South Asian Parents and Navigators Action) for Child Oral Health, a home visit-based intervention designed to reduce childhood caries risk in low income families in New York City. Sixty-one South Asian families were recruited from pediatric practices and randomized into intervention and control groups. Seventy-five percent of participants were retained in the study; 100% of intervention participants received the full dose of the intervention. Though the study was not designed to detect group differences, a broad pattern of such differences was found, with positive changes in feeding, oral hygiene and preventive dental care greater in the intervention group. Findings suggest that the SAPNA model is acceptable, feasible and potentially efficacious. [ABSTRACT FROM AUTHOR]