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Food environments can contribute to excess weight gain among adults, but the evidence is mixed.This longitudinal study investigates the association between changes in the food environment and changes in body mass index (BMI) in adults and whether changes in the food environment differentially impact various subgroups.At two time points, BMI was calculated using self-reported height and weight data from 517 adults (mean age, 41 years) living in four New Jersey cities. The count of different types of food outlets within 0.4, 0.8, and 1.6 km of respondents' residences was collected at baseline and tracked until follow-up. A binary measure of social standing (social advantage, n = 219 vs social disadvantage, n = 298) was created through latent class analysis using social, economic, and demographic variables. Multivariable linear regression modelled the association between changes in BMI with measures of the food environment; additionally, interaction terms between the measures of social standing and the food environment were examined.Overall, over 18 months, an increase in the number of small grocery stores within 0.4 km of a respondent's residence was associated with a decrease in BMI (β = -1.0, 95% CI: -1.9, -0.1, P = 0.024), while an increase in the number of fast-food restaurants within 1.6 km was associated with an increase in BMI (β = 0.1, 95% CI: 0.01, 0.2, P = 0.027). These overall findings, however, masked some group-specific associations. Interaction analyses suggested that associations between the food environment and change in BMI vary by social standing. For instance, the positive association between changes in fast-food restaurants and changes in BMI was only observed in the social disadvantage group (β = 0.1, 95% CI: 0.02, 0.2, P = 0.021).In a sample of adults living in New Jersey, changes in food environment had differential effect on individuals' BMI based on their social standing.

The 2010 Healthy, Hunger-Free Kids Act (HHFKA) improved the nutritional quality of food served in schools. This longitudinal study examined school food offerings over time from school year 2010-11 to 2017-18 in public schools (n = 148) in four New Jersey cities. Six food indices were used to assess the number of healthy and unhealthy items offered as part of the National School Lunch Program (NSLP), in vending machines, and à la carte (i.e., competitive foods). Multilevel, multivariable linear regression with quadratic terms was used to model the trends over time. Interaction terms were added to examine whether the time trends varied by school-level factors, such as proportion of students eligible for free or reduced-price meals (FRPMs), race/ethnicity of enrolled students, and school level. Over the study period, healthy items offered in the NSLP increased (p < 0.001), while unhealthy items in the NSLP decreased (p < 0.001). Significantly different rates of declines in NSLP unhealthy offering were observed among schools at the two extremes of FRPM eligibility (p < 0.05). The trends for healthy and unhealthy foods offered in competitive foods showed significant non-linear trends, and differences were observed for school-level race/ethnicity, with worse outcomes for schools with majority Black student enrollment.

OBJECTIVES: To examine (1) parental perceptions of school meals and (2) student meal participation before and after the implementation of the Healthy Hunger-Free Kids Act (HHFKA). DESIGN: Data were collected from telephone surveys of 2 independent cross-sectional panels in New Jersey (2009–2010 and 2016–2017). PARTICIPANTS: Households with children aged 7–18 years (pre-HHFKA: n = 1,027; post-HHFKA: n = 324). MAIN OUTCOME MEASURES: Parental perception of school meals and parental reports of student participation in school meals. ANALYSIS: Multivariable logistic regression models were developed to examine outcome variables. For school meal participation, nested models were analyzed first controlling for sociodemographic variables, followed by parental perception, and then the interaction between perception and time. RESULTS: Parental perceptions of school meals did not change significantly after the HHFKA. At both time points, school meal participation rates were significantly higher for children of parents who perceived school meals as healthy compared with children whose parents perceived meals to be unhealthy (pre-HHFKA: 89.9% vs 75.1%, P < 0.001; post-HHFKA: 87.3% vs 64.9%, P = 0.02). CONCLUSION AND IMPLICATIONS: Because higher perception of school meal quality is associated with higher participation, it is important for school food programs to inform parents about the improved nutritional quality of school meals.

The New Jersey Medicaid Accountable Care Organization (ACO) Demonstration was created with a unique combination of features regarding ACO geography, involvement of managed care organizations (MCOs), and shared savings parameters. Ultimately, the Demonstration did not lead to a sustainable accountable care financing model and shared savings were deemphasized. Instead, the ACOs evolved into community health coalitions focused on coordinating and enhancing a wide range of activities in partnership with state government, private health systems, community leaders, and MCOs. Currently, the state is developing policy parameters to reposition the ACOs as regional partners to implement state-directed population health initiatives.

Exposures to favorable environments in childhood, including those in schools, are associated with healthy habits among children. In this study, we developed a series of indices aimed at measuring students' exposure to different dimensions of the school food and physical activity (PA) environment. We implemented these indices to investigate how different aspects of the school food and PA environment changed over time and examined their correspondence with known changes in relevant policies and programs.All public schools (n= 141) in four school districts in New Jersey provided detailed food and PA environment data for each school year from 2010-2011 to 2015-2016. Seven food environment indices, three PA environment indices, and two additional indices that capture health-promoting initiatives at the school level and at the state or federal level were developed.Although the school PA environment largely remained unchanged, several dimensions of the school food environment changed between 2010-2011 and 2015-2016. Overall, the number of healthy items increased over time in vending machines (p.001), a la carte (p.05), or through reimbursable school lunches (p.001); decreases in number of unhealthy items were only detected in school lunches (p.05). For most food indices, both the number of items offered and the trend over time varied across school levels.Schools are a key venue for implementing policy and environment interventions aimed to promote healthy behaviors. Indices developed from easy-to-use survey questions captured multiple dimensions of the school food and PA environments and were sensitive to policy changes over time.

Background Participation in the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC) among 0- to 5-year-old children is associated with healthier diets. Extension of dietary benefits to older, age-ineligible children (5-18 years old) residing in WIC households has not been fully investigated. Objective Examine the association between household WIC participation and dietary behaviors of age-ineligible children. Design Cross-sectional secondary analysis of data collected from 2 independent panels (2009-2010 and 2014) of the New Jersey Child Health Study, using household surveys. Questions derived from national surveys assessed consumption frequency of specific foods among 5- to 18-year-old children. Participants/setting The analytic sample included 616 age-ineligible children from households with incomes below 200% of the federal poverty level, 398 of whom were from WIC-participating households. Main outcome measures Eating behaviors were measured as frequency of daily consumption of fruit, vegetables, 100% juice, sugar-sweetened beverages, and sweet and salty snacks. Statistical analysis Multivariable negative binomial models examined the association between eating behaviors and household WIC participation status adjusting for child's age, sex, and race; mother's education; city of residence; household size; and panel. Results are expressed as incidence rate ratios (IRRs). Results Household WIC participation was not associated with dietary behaviors among age-ineligible children (5-18 years old) in the overall sample. However, healthier dietary patterns were observed for specific demographic groups. Compared with age-ineligible children in non-WIC households, age-ineligible children in WIC households had (1) a higher frequency of vegetable consumption among 12- to 18-year-old children (IRR = 1.29; 95% confidence interval [CI] 1.05-1.58; P = .015); (2) a marginally significant higher frequency of 100% juice consumption among females (IRR = 1.27; 95% CI 1.00-1.62; P = .053); and (3) a lower frequency of sugar-sweetened beverages consumption among Hispanic children (IRR = 0.61; 95% CI 0.43-0.86; P = .004). Conclusions Household WIC participation may positively influence dietary behaviors of age-ineligible children, suggesting a possible WIC spillover effect. Revisions to WIC package composition should consider the possible dietary implications for all children in the household.

BACKGROUND Strategies to improve the community food environment have been recommended for addressing childhood obesity, but evidence substantiating their effectiveness is limited. OBJECTIVE Our aim was to examine the impact of changes in availability of key features of the community food environment, such as supermarkets, small grocery stores, convenience stores, upgraded convenience stores, pharmacies, and limited service restaurants, on changes in children's body mass index z scores (zBMIs). DESIGN We conducted a longitudinal cohort study. PARTICIPANTS/SETTING Two cohorts of 3- to 15-year-old children living in 4 low-income New Jersey cities were followed during 2- to 5-year periods from 2009 through 2017. Data on weight status were collected at 2 time points (T1 and T2) from each cohort; data on food outlets in the 4 cities and within a 1-mile buffer around each city were collected multiple times between T1 and T2. MAIN OUTCOME MEASURES We measured change in children's zBMIs between T1 and T2. STATISTICAL ANALYSIS Changes in the food environment were conceptualized as exposure to changes in counts of food outlets across varying proximities (0.25 mile, 0.5 mile, and 1.0 mile) around a child's home, over different lengths of time a child was exposed to these changes before T2 (12 months, 18 months, and 24 months). Multivariate models examined patterns in relationships between changes in zBMI and changes in the food environment. RESULTS Increased zBMIs were observed in children with greater exposure to convenience stores over time, with a consistent pattern of significant associations across varying proximities and lengths of exposure. For example, exposure to an additional convenience store over 24 months within 1 mile of a child's home resulted in 11.7% higher odds (P = 0.007) of a child being in a higher zBMI change category at T2. Lower zBMIs were observed in children with increased exposure to small grocery stores selling an array of healthy items, with exposure to an additional small grocery store within 1 mile over 24 months, resulting in 37.3% lower odds (P < 0.05) of being in a higher zBMI change category at T2. No consistent patterns were observed for changes in exposure to supermarkets, limited service restaurants, or pharmacies. CONCLUSIONS Increased availability of small grocery stores near children's homes may improve children's weight status, whereas increased availability of convenience stores is likely to be detrimental.

Background Patients who heavily utilize hospitals and emergency departments frequently have complex needs requiring services spanning medical, behavioral, and social service sectors. This study identifies essential competencies for caring for high-needs patients and highlights their importance to primary care delivery. Methods Transcripts of in-depth interviews with 30 clinical and administrative staff at 23 complex care programs across the United States were analyzed using standard qualitative techniques. Selected programs had several years of experience in serving patients with multiple chronic conditions, serious mental illness, substance use disorders, severe poverty, and homelessness. These programs exemplified diverse models (assertive community treatment, housing first, behavioral health, high utilizer), and all of them shared the common element of integrating primary care into their services. Results Competencies, including those known and taught in other fields, have distinctive application to informing delivery of high quality primary care to populations with complex needs, including: motivational interviewing for establishing patients’ priorities and helping them improve their health on their own terms; trauma-informed care for modifying primary care procedures to mitigate the ill-effects of prior trauma prevalent in this population; and harm reduction for altering medical regimens to accommodate constraints on what patients are able or willing to do. Other capabilities, cultivated by these programs, include empathizing with patients, promoted by exposure to simulations of patient experiences (e.g., hearing voices); as well as withholding judgment and counteracting patient passivity to foster open discussion of treatment plans. Conclusions Absence of deliberate attention to equipping providers with specific competencies for caring for high-needs patients may contribute to lack of patient engagement and sub-optimal outcomes, ultimately undermining the success of programs serving these populations.

Background Understanding determinants of high consumption of sugar-sweetened beverages (SSBs), a highly prevalent obesogenic behavior, will help build effective customized public health interventions. Objective Our aim was to identify child and parent lifestyle and household demographic factors predictive of high SSB consumption frequency in children from low-income, ethnically diverse communities that may help inform public health interventions. Design We used a cross-sectional telephone household survey. Participants/setting Participants were 717 boys and 686 girls aged 3 to 18 years old from the New Jersey Childhood Obesity Study living in five low-income cities (Camden, New Brunswick, Newark, Trenton, and Vineland). The adult most knowledgeable about household food shopping completed a questionnaire over the telephone inquiring about their and their child's dietary and physical activity habits, and household-, parent-, and child-level demographics. Main outcome measures Child's SSB consumption frequency was measured. Statistical analysis performed Multivariate ordered logit models were designed to investigate a variety of variables hypothesized to affect the frequency of SSB consumption. Exploratory stratified analyses by race, sex, and age were also conducted. Results Eight percent of our study participants never consumed SSBs, 45% consumed SSBs at least once per day, and 23% consumed twice or more per day. SSB consumption was higher among children 12 to 18 years vs 3 to 5 years ( P P =0.010), who were moderate fast food consumers vs never consumers ( P =0.003), and those whose parents were high vs low SSB consumers ( P P =0.030), having a parent with a college or higher education vs less than high school ( P =0.003), and having breakfast 6 to 7 days/wk vs never to 2 days/wk or less were associated with lower SSB consumption ( P =0.001). Conclusions We identified a number of household-, parent-, and child-level predictors of SSB consumption, which varied by race, sex, and age, useful for building customized interventions targeting certain behaviors in ethnically diverse, low-income children.

Disparities in healthy food access are well documented in cross-sectional studies in communities across the United States. However, longitudinal studies examining changes in food environments within various neighborhood contexts are scarce. In a sample of 142 census tracts in four low-income, high-minority cities in New Jersey, United States, we examined the availability of different types of food stores by census tract characteristics over time (2009&ndash, 2017). Outlets were classified as supermarkets, small grocery stores, convenience stores, and pharmacies using multiple sources of data and a rigorous protocol. Census tracts were categorized by median household income and race/ethnicity of the population each year. Significant declines were observed in convenience store prevalence in lower- and medium-income and majority black tracts (p for trend: 0.004, 0.031, and 0.006 respectively), while a slight increase was observed in the prevalence of supermarkets in medium-income tracts (p for trend: 0.059). The decline in prevalence of convenience stores in lower-income and minority neighborhoods is likely attributable to declining incomes in these already poor communities. Compared to non-Hispanic neighborhoods, Hispanic communities had a higher prevalence of small groceries and convenience stores. This higher prevalence of smaller stores, coupled with shopping practices of Hispanic consumers, suggests that efforts to upgrade smaller stores in Hispanic communities may be more sustainable.

BACKGROUND: The United States Department of Agriculture’s Supplemental Nutrition Assistance Program (SNAP) is the country’s largest nutrition assistance program for low-income populations. While SNAP has been shown to reduce food insecurity, research on the diet quality of program participants is inconsistent. OBJECTIVE: This study examined if the community food environment is a potential moderator of the association between SNAP participation and eating behaviors. DESIGN: This cross-sectional study utilized participant data from a telephone survey of 2,211 households in four cities in New Jersey. Data were collected from two cross-sectional panels from 2009–10 and 2014. Food outlet data were purchased from commercial sources and classified as supermarkets, small grocery stores, convenience stores, or limited service restaurants. PARTICIPANTS/SETTING: Analysis is limited to 983 respondents (588 SNAP participants) with household incomes below 130% of the Federal Poverty Level. MAIN OUTCOME MEASURES: Eating behaviors assessed as frequency of consum ption of fruit, vegetables, salad, and sugar sweetened beverages (SSB). STATISTICAL ANALYSIS PERFORMED: Interaction and stratified analyses using gamma regression determined the differences in the association between SNAP participation and eating behaviors by the presence or absence of food outlets adjusted for covariates. RESULTS: SNAP participation was associated with a higher frequency of consuming SSB (p

Purpose:To develop a valid and feasible short-form corner store audit tool (SCAT) that could be used in-store or over the phone to capture the healthfulness of corner stores.Design:Nonexperimental.Setting:Four New Jersey cities.Subjects:Random selection of 229 and 96 corner stores in rounds 1 and 2, respectively.Measures:An adapted version of the Nutrition Environment Measures Survey for Corner Stores (NEMS-CS) was used to conduct in-store audits. The 7-item SCAT was developed and used for round 2 phone audits.Analysis:Exploratory factor analysis and item response theory were used to develop the SCAT.Results:The SCAT was highly correlated with the adapted NEMS-CS ( r = .79). Short-form corner store audit tool scores placed stores in the same healthfulness categories as did the adapted NEMS-CS in 88% of the cases. Phone response matches indicated that store owners did not distinguish between 2% and low-fat milk and tended to round up the fruit and vegetable count to 5 if they had fewer varieties.Conclusion:The SCAT discriminates between higher versus lower healthfulness scores of corner stores and is feasible for use as a phone audit tool.

Objectives. To determine the proportion of restaurants that will be required to post calorie information under the Food and Drug Administration’s menu-labeling regulations in 4 New Jersey cities. Methods. We classified geocoded 2014 data on 1753 restaurant outlets in accordance with the Food and Drug Administration’s guidelines, which will require restaurants with 20 or more locations nationwide to post calorie information. We used multivariate logistic regression analyses to assess the association between menu-labeling requirements and census tract characteristics. Results. Only 17.6% of restaurants will be affected by menu labeling; restaurants in higher-income tracts have higher odds than do restaurants in lower-income tracts (odds ratio [OR] = 1.55; P = .02). Restaurants in non-Hispanic Black (OR = 1.62; P = .02) and mixed race/ethnicity (OR = 1.44; P = .05) tracts have higher odds than do restaurants in non-Hispanic White tracts of being affected. Conclusions. Additional strategies are needed to help consumers make healthy choices at restaurants not affected by the menu-labeling law. These findings have implications for designing implementation strategies for the law and for evaluating its impact.

Relationships between food and physical activity (PA) environments and children's related behaviors are complex. Latent class analyses derived patterns from proximity to healthy and unhealthy food outlets, PA facilities and parks, and counts of residential dwellings and intersections. Regression analyses examined whether derived classes were related to food consumption, PA, and overweight among 404 low-income children. Compared to children living in Low PA-Low Food environments, children in High Intersection&Parks-Moderate Density&Food, and High Density-Low Parks-High Food environments, had significantly greater sugar-sweetened beverage consumption (ps

A small but growing number of states are turning to accountable care concepts to improve their Medicaid programs. In 2011 New Jersey enacted the Medicaid Accountable Care Organization (ACO) Demonstration Project to offer local provider coalitions the opportunity to share any savings they generate. Impetus came from initiatives in Camden that aim to reduce costs through improved care coordination among hospital high users and that have received considerable media attention and substantial federal and private grant support. Though broadly similar to Medicare and commercial ACOs, the New Jersey demonstration addresses the unique concerns faced by Medicaid populations. Using hospital all-payer billing data, we estimate savings from care improvement efforts among inpatient and emergency department high users in thirteen communities that are candidates for participation in the New Jersey demonstration. We also examine their characteristics to inform Medicaid accountable care strategies. We find substantial variation in the share of high-user hospital patients across the study communities and high rates of avoidable use and costs among these patients. The potential savings among Medicaid enrollees are considerable, particularly if Medicaid ACOs can develop ways to successfully address the high burden of chronic illness and behavioral health conditions prevalent in the prospective demonstration communities.

This cohort study assesses whether parent measurements of children’s height and weight are more accurate than their respective estimates for determining weight status and how both compare with professionally measured data.

BACKGROUND: Few children accumulate the recommended ≥60 minutes of physical activity each day. Active travel to and from school (ATS) is a potential source of increased activity for children, accounting for 22% of total trips and time spent traveling by school-aged children. PURPOSE: This study identifies the association of parents' perceptions of the neighborhood, geospatial variables, and demographic characteristics with ATS among students in four low-income, densely populated urban communities with predominantly minority populations. METHODS: Data were collected in 2009-2010 from households with school-attending children in four low-income New Jersey cities. Multivariate logistic regression analyses (n=765) identified predictors of ATS. Analyses were conducted in 2012. RESULTS: In all, 54% of students actively commuted to school. Students whose parents perceived the neighborhood as very unpleasant for activity were less likely (OR=0.39) to actively commute, as were students living farther from school, with a 6% reduction in ATS for every 0.10 mile increase in distance to school. Perceptions of crime, traffic, and sidewalk conditions were not predictors of ATS. CONCLUSIONS: Parents' perceptions of the pleasantness of the neighborhood, independent of the effects of distance from school, may outweigh concerns about crime, traffic, or conditions of sidewalks in predicting active commuting to school in the low-income urban communities studied. Efforts such as cleaning up graffiti, taking care of abandoned buildings, and providing shade trees to improve neighborhood environments are likely to increase ATS, as are efforts that encourage locating schools closer to the populations they serve. Language: en

To examine the impact of a chronic care residency training intervention on continuity clinic patients' asthma-related emergency department use and primary care residents' application of key elements of the Chronic Care Model (CCM).In 2002 and 2003, the authors conducted a pre- and posttraining survey of 41 intervention residents at Maine Medical Center to assess residents' implementation of the CCM. The change in implementation for intervention residents was compared with that of 77 primary care residents not receiving CCM training. Asthma-related emergency department (ED) use by 441 patients cared for by intervention residents was compared with that of other asthma patients at Maine Medical Center using hospital billing records.At baseline, residents in both groups reported sporadic application of key elements of the CCM. At posttest, Maine Medical Center residents reported significantly greater increases in CCM implementation than the comparison group for 4 out of the 12 items. The greatest increases were in residents' access to asthma guidelines, the proportion of patients receiving written asthma management plans, and residents' access to information on community asthma programs. The number of asthma-related ED visits dropped significantly among patients treated by intervention residents (pediatric patients 42%, adults 44%). There was a slight increase in asthma ED use for nonintervention pediatric patients at the hospital (8%) and a very small decrease for adults (3%).Chronic care training programs for residents may influence the health outcomes of patients treated in their continuity clinics while simultaneously offering an important educational experience in an underemphasized area of medicine.

Palliative care was studied for its potential to yield lessons for transforming doctor-patient relationships to promote patient-centered care. Examination of patient and provider experiences of the transition from curative to palliative care promises valuable insights about establishing and maintaining trust as the goals of care shift and about addressing a broad spectrum of patient needs. The study was guided by a conceptual framework grounded in existing models to address five dimensions of doctor-patient relationships: range of needs addressed, source of authority, maintenance of trust, emotional involvement, and expression of authenticity. Data collection included observation of the care of 40 patients in the inpatient hospice unit and at home, interviews with patients and family members, and in-depth interviews with 22 physicians and two nurses providing end-of-life care. Standard qualitative procedures were used to analyze the data, incorporating techniques for maximizing the validity of the results and broadening their relevance to other contexts. Findings provide evidence for challenging prominent assumptions about possibilities for doctor-patient relationships: questioning the merits of the prohibition on emotional involvement, dependence on protocols for handling difficult communication issues, unqualified reliance on consumer empowerment to assure that care is responsive to patients' needs, and adoption of narrowly defined boundaries between medical and social service systems in caring for patients. Medical education can play a role in preparing doctors to assume new roles by openly addressing management of emotions in routine clinical work, incorporating personal awareness training, facilitating reflection on interactions with patients through use of standardized patients and videotapes, and expanding capacity to effectively address a broad range of needs through teamwork training.

This study assessed how resident psychiatrists are being prepared to deliver effective public-sector care.Ten leaders in psychiatric education and practice were interviewed about which tasks they consider to be essential for effective public-sector care. The leaders identified 16 tasks. Directors of all general psychiatry residency programs in the United States were then surveyed to determine how they rate the importance of these tasks for delivery of care and how their training program prepares residents to perform each task.A total of 114 of 150 residency directors (76 percent) responded to the survey. Factor analysis divided 14 of the tasks into three categories characterized by the extent to which their performance requires integration of services: within the mental health system (for example, lead a multidisciplinary team), across social service systems (for example, interact with staff of supportive housing programs), and across institutions with different missions (for example, distinguish behavioral problems from underlying psychiatric disorders among prisoners). Preparation for tasks that involved integration of services across institutions was rated as least important, was least likely to be required, and was covered by less intensive teaching modalities. Tasks entailing integration within the mental health system were rated as most important, preparation was most likely to be required, and they were covered most intensively. Midway between these two categories, but significantly different from each, were tasks relying on integration across social service systems.Tasks that involved integrating services across institutions with different missions were consistently downplayed in training. Yet the importance of such tasks is underscored by the assessments of the psychiatric leaders who were interviewed, the high valuation placed on this type of integration by a substantial subset of training directors, and the extent of mental illness among populations who are institutionalized in nonpsychiatric settings.

Background Delayed or incomplete follow-up after abnormal screening results may compromise the effectiveness of breast cancer screening programs, particularly in medically underserved and minority populations. This study examined the role of socioeconomic status, breast cancer risk factors, health care system barriers, and patient cognitive–attitudinal factors in the timing of diagnostic resolution after abnormal breast cancer screening exams among Black women receiving breast cancer screening at three New York city clinics. Methods We identified 184 Black women as having an abnormal mammogram or clinical breast exam requiring immediate follow-up and they were interviewed and their medical records examined. Bivariate and multivariate logistic regression analyses were used to assess the association between patient and health care system factors and diagnostic resolution within 3 months of the abnormal finding. Results Within 3 months, 39% of women were without diagnostic resolution and 28% within 6 months. Neither socioeconomic status nor system barriers were associated with timely diagnostic resolution. Timely resolution was associated with mammogram severity, patients asking questions (OR, 2.73; 95% CI, 1.25–5.96), or receiving next step information (OR, 2.6; 95% CI, 1.08–6.21) at the initial mammogram. Women with prior breast abnormalities were less likely to complete timely diagnostic resolution (OR, 0.42; 95% CI, 0.20–0.85), as were women with higher levels of cancer anxiety (OR, 0.50; 95% CI, 0.27–0.92). Conclusions Interventions that address a woman’s prior experience with abnormal findings and improve patient/provider communication may improve timely and appropriate follow-up.

To identify dominant themes characterizing patients' perspectives on death during their last months of life, an ethnographic technique of interviewing and an inductive qualitative approach to analysis were employed. Serial, in-depth, semi-structured interviews were conducted with 30 patients (mean = 4.2 interviews/patient) followed as close to the time of death as possible. The interviews were audiotaped, transcribed, and subjected to independent analysis by both authors using standard qualitative techniques. Patients were referred to the study by Beth Israel Medical Center clinicians if they had a diagnosis of a life-threatening condition of which they were aware; were likely to die within one year according to their physician; had experienced symptoms of the illness; were sufficiently alert to discuss the topics addressed in the study; conversed easily in English; and consented to participate. Outlooks on dying were thoroughly grounded in patients' frames of reference for giving meaning and consistency to other major events in their lives. Seven motifs characterizing these perspectives on death were distilled: struggle (living and dying are difficult), dissonance (dying is not living), endurance (triumph of inner strength), coping (finding a new balance), incorporation (belief system accommodates death), quest (seeking meaning in death), and volatile (unresolved and unresigned). Patients demonstrated a striking capacity for coherence, integrating their responses to dying with broader motifs in their life stories. Health care providers would be well advised to become aware of such motifs so as to better understand patient preferences for care and responses to treatment recommendations.

The current and projected nurse faculty shortage threatens the capacity to educate sufficient numbers of nurses for meeting demand. As part of an initiative to foster strategies for expanding educational capacity, a survey of a nationally representative sample of 3,120 full-time nurse faculty members in 269 schools and programs that offered at least one prelicensure degree program was conducted. Nearly 4 of 10 participants reported high levels of emotional exhaustion, and one third expressed an intent to leave academic nursing within 5 years. Major contributors to burnout were dissatisfaction with workload and perceived inflexibility to balance work and family life. Intent to leave was explained not only by age but by several potentially modifiable aspects of work, including dissatisfaction with workload, salary, and availability of teaching support. Preparing sufficient numbers of nurses to meet future health needs will require addressing those aspects of work–life that undermine faculty teaching capacity. [ J Nurs Educ. 2014;53(10):569–579.]

Little evidence exists examining if parental nativity, neighborhood disadvantage and built environment features are associated with physical activity behaviors in Latino youth. We used a representative sample of Latino youth (n = 616) living in New Jersey to examine parental nativity associations with active transport to school, active use of sidewalks, use of local neighborhood parks, and use of neighborhood physical activity facilities. We estimated prevalence ratios (PR) that accounted for the complex survey design. Latino youth with foreign-born parents were generally more active than their US-born peers, and those with parents in the US 10 years or less were more likely to engage in active transport to school (PR = 1.51, 95 % CI 1.04–2.21), after adjusting for census-based neighborhood disadvantage, self-reported neighborhood measures, and geocoded distance to school. Parental nativity status should be considered in policies or interventions designed to increase physical activity among Latino youth.

Objectives Conflicting findings on associations between food and physical activity (PA) environments and children's weight status demand attention in order to inform effective interventions. We assess relationships between the food and PA environments in inner-city neighborhoods and children's weight status and address sources of conflicting results of prior research. Methods Weight status of children ages 3–18 was assessed using parent-measured heights and weights. Data were collected from 702 children living in four low-income cities in New Jersey between 2009 and 2010. Proximity of a child's residence to a variety of food and PA outlets was measured in multiple ways using geo-coded data. Multivariate analyses assessed the association between measures of proximity and weight status. Results Significant associations were observed between children's weight status and proximity to convenience stores in the 1/4 mile radius (OR = 1.9) and with presence of a large park in the 1/2 mile radius (OR = 0.41). No associations were observed for other types of food and PA outlets. Conclusions Specific aspects of the food and PA environments are predictors of overweight and obese status among children, but the relationships and their detection are dependent upon aspects of the geospatial landscape of each community.

To explore the impact of internal medicine residents' roles as learners, teachers, and physicians on their performance in teaching and supervising interns; to generate insights for educational policy and research.Qualitative analysis of in-depth, semistructured, recorded interviews with a cohort of second-postgraduate-year (PGY-2) residents. Questions elicited their accounts of differences in the learning process between the first and second residency years, their responses to situations in which they lacked sufficient clinical knowledge, their views of their supervisory relationship with interns, and their assessments of changes in their role in patient care since their internships. Transcripts were independently analyzed by the interdisciplinary team of authors.New York University/Bellevue Hospital Center's internal medicine residency (New York City), a highly competitive program in a major public hospital and a university medical center, emphasizing housestaff autonomy and self-reliance.A cohort of 18 of 21 medical residents at Bellevue Hospital Center during the last rotation of PGY-2.Intense conflicts confound residents' roles as teachers. These conflicts fall into three categories: 1) as learners, residents' own needs frequently coincide with those of interns in ways that may undermine their teaching--they are expected to nurture others despite their own considerable needs for emotional support, teach material that they barely grasp, and exert authority while feeling ignorant; 2) as team leaders, residents must ensure that interns get the hospital's work done, sometimes at the expense of teaching them; and 3) as clinicians, residents' first priority is to address the medical needs of patients--the learning needs of interns are secondary.Second-year internal medicine residents experience conflicts inherent in their simultaneous commitment to learning, teaching, and service that may undermine both their effectiveness in supervising interns and their own professional development. Potential remedies are to restructure residency programs so as to equip residents with training and support for their role as teachers, reduce the tension between training and service by delegating tasks to nonphysician personnel, and provide graded responsibility to housestaff as physicians and teachers.

Purpose. Assessing food environments often requires using commercially available data. Disparate methods used for classifying food outlets in these databases call for creating a classification approach using common definitions. A systematic strategy for reclassifying food stores and restaurants, as they appear in commercial databases, into categories that differentiate the availability of healthy options is described here. Design and Setting. Commercially available data on food outlets including names, addresses, North American Industry Classification System codes, and associated characteristics was obtained for five New Jersey communities. Analysis. A reclassification methodology was developed using criteria and definitions from the literature to categorize food outlets based on availability of healthy options. Information in the database was supplemented by systematic Internet and key word searches, and from phone calls to food outlets. Results. The methodology resulted in 622 supermarket/grocery stores, 183 convenience stores, and 148 specialty stores in the original data to be reclassified into 58 supermarkets, 30 grocery stores, 692 convenience stores, and 115 specialty stores. Outlets from the original list of 1485 full-service restaurants and 506 limited-service restaurants were reclassified as 563 full-service restaurants and 1247 limited-service restaurants. Reclassification resulted in less than one-seventh the number of supermarkets and grocery stores, more than three times the number of convenience stores, and twice as many limited-service restaurants—a much less healthy profile than the one generated by using exclusively the commercial databases. Conclusion. An explicit and replicable strategy is proposed for reclassifying food outlets in commercial databases into categories that differentiate on the basis of healthy food availability. The intent is to contribute towards building a consensus among researchers on definitions used in public health research for characterizing different types of food outlets.

(2008). HOW DO FAMILY CAREGIVERS DESCRIBE THEIR NEEDS FOR PROFESSIONAL HELP? Journal of Social Work Education: Vol. 44, No. sup3, pp. 43-47.

Effective treatment of chronic illness requires active engagement of patients in managing their own conditions. This research explores the influence of provider support for self-management on patients' performance of self-care activities, a widely presumed but under-studied relationship, particularly among underserved populations. We surveyed an ethnically diverse, primarily low-income sample of 956 patients (or parents of pediatric patients) with diabetes or asthma in 17 outpatient teaching settings across the country. Multivariate analysis established that patients with strongly positive assessments of their providers were substantially more confident in self-care. Further, among patients with diabetes, high assessments of provider support, in comparison with low, were significantly associated with performance of self-management tasks, amounting to approximately one more day per week. These relationships were significant for patients with either illness and from varied socio-economic backgrounds. The results provide evidence of the validity of our measure of provider support, its relevance to underserved populations, and its usefulness for evaluating quality of care.

Residency programs must prepare physicians to practice in the current health care environment. This mandate is reflected in 3 of the 6 competency domains now required by the Accreditation Council for Graduate Medical Education: systems-based practice, interpersonal skills and communication, and practice-based learning and improvement.An invitational conference was convened, with experts in clinical practice, managed care administration, and education to identify and recommend optimal and promising assessment methods for 4 target areas: physician-patient communication, ethics, teamwork and collaboration, and practice management. Working in small groups, participants considered a range of resident assessment methods and identified current or future methods for each area, based on reliability, validity, use of behaviorally oriented outcomes, feasibility, and cost. Preferred methods of assessment varied by domain and include written examinations, computer-based patient management problems, standardized patients, objective structured clinical examinations, portfolios, 360-degree evaluations, and patient satisfaction surveys.The use of several practical, scientifically sound, and specific methods for assessing residents' competency in care management are recommended. Assessment instruments will need to be flexible enough to adapt to the rapid changes in the health care delivery system and terminology.

ContextAlthough physicians' communication skills have been found to be related to clinical outcomes and patient satisfaction, teaching of communication skills has not been fully integrated into many medical school curricula or adequately evaluated with large-scale controlled trials.ObjectiveTo determine whether communications training for medical students improves specific competencies known to affect outcomes of care.Design and SettingA communications curriculum instituted in 2000-2001 at 3 US medical schools was evaluated with objective structured clinical examinations (OSCEs). The same OSCEs were administered to a comparison cohort of students in the year before the intervention.ParticipantsOne hundred thirty-eight randomly selected medical students (38% of eligible students) in the comparison cohort, tested at the beginning and end of their third year (1999-2000), and 155 students in the intervention cohort (42% of eligible students), tested at the beginning and end of their third year (2000-2001).InterventionComprehensive communications curricula were developed at each school using an established educational model for teaching and practicing core communication skills and engaging students in self-reflection on their performance. Communications teaching was integrated with clinical material during the third year, required clerkships, and was supported by formal faculty development.Main Outcome MeasuresStandardized patients assessed student performance in OSCEs on 21 skills related to 5 key patient care tasks: relationship development and maintenance, patient assessment, education and counseling, negotiation and shared decision making, and organization and time management. Scores were calculated as percentage of maximum possible performance.ResultsAdjusting for baseline differences, students exposed to the intervention significantly outperformed those in the comparison cohort on the overall OSCE (65.4% vs 60.4%; 5.1% difference; 95% confidence interval [CI], 3.9%-6.3%; P

High false positive rates associated with screening for breast cancer in the United States have an unintended psychological consequence for women (Lerman et al., 1991) that has raised concerns in recent years (Sox, 1998). This study uses inductive qualitative analysis of open-ended interviews with 45 African American women living in New York City who were part of a larger study of women and their experiences after receiving an abnormal mammogram. Themes resulting from the analyses included: inadequate provider-patient communication, anxieties exacerbated by waiting and wondering, and fears of iatrogenic effects of follow-up tests such as biopsies and repeat mammograms. While more research is needed on message-framing strategies for women entering mammographic testing and follow-up, modest changes in service de livery such as improved medical communication can help to alleviate fears and enhance trust.

A scarcity of women in leadership positions in academic medicine has persisted despite their increasing numbers in medical training. To understand the barriers confronting women and potential remedies, clinical department chairs with extensive leadership experience were interviewed.In 1998-99, open-ended interviews averaging 80 minutes in length were conducted with 34 chairs and two division chiefs in five specialties. Individuals were selected to achieve a balance for gender, geographic locale, longevity in their positions, and sponsorship and research intensity of their institutions. The interviews were audiotaped and fully transcribed, and the themes reported emerged from inductive analysis of the responses using standard qualitative techniques.The chairs' responses centered on the constraints of traditional gender roles, manifestations of sexism in the medical environment, and lack of effective mentors. Their strategies for addressing these barriers ranged from individual or one-on-one interventions (e.g., counseling, confronting instances of bias, and arranging for appropriate mentors) to institutional changes (e.g., extending tenure probationary periods, instituting mechanisms for responding to unprofessional behavior, establishing mentoring networks across the university).The chairs universally acknowledged the existence of barriers to the advancement of women and proposed a spectrum of approaches to address them. Individual interventions, while adapting faculty to requirements, also tend to preserve existing institutional arrangements, including those that may have adverse effects on all faculty. Departmental or school-level changes address these shortcomings and have a greater likelihood of achieving enduring impact.

ContextAlthough medical educators recognize the need to prepare physicians to work effectively in managed care environments, managed care is often perceived negatively by academic physicians. Curricular reform has been hampered by a failure to seek agreement about specific clinical competencies that are important to both managed care directors and medical educators.ObjectivesTo identify specific clinical competencies in the managed care setting and to assess agreement between residency directors and managed care medical directors on the importance of these competencies.Design, Setting, and ParticipantsSurveys (1998-1999) of a national sample of 59 residency directors involved in managed care training programs (response rate, 94%); a sample of 186 residents in these programs and 258 matched control residents (response rate, 77%); and national samples of 147 managed care organization (MCO) medical directors (response rate, 67%) and 140 primary care residency program directors in areas of high MCO penetration (response rate, 73%).Main Outcome MeasuresSpecific clinical managed care tasks as defined by residency directors; self-reported confidence in performing these tasks by sample residents vs control residents; and importance of these tasks as rated by MCO medical directors and residency program directors.ResultsTwenty-six specific clinical managed care tasks were identified by the residency directors. Residents who participated in managed care training were significantly more confident than their counterparts in performing 20 of the 26 tasks (P

PURPOSE: To determine the effects of aspects of residency training on AIDS-related treatment practices. METHOD: The authors conducted a nationwide longitudinal panel study of 394 physicians who graduated in 1989 from six medical schools in New York State. Data were collected during the participants' fourth year of medical school, their third year of residency training, and six years after they had graduated from medical school. Questionnaires sought information about AIDS-related practice behaviors, including avoiding invasive procedures, minimizing contact, emphasizing AIDS prevention and education, and volume of people with AIDS treated. RESULTS: Aspects of residency training had a sustained impact on how the physicians cared for patients with AIDS but not on the numbers of patients they treated. Determinants of treatment practices included aspects of the residency environment (e.g., emphasis on problem solving, student orientation; p < .01), characteristics of the faculty (e.g., commitment to teaching, tolerance of varied viewpoints), cynicism about patient care (p < .001), social biases (homophobia and aversion to intravenous drug users; p < .001), and AIDS-related attitudes (p < .01). CONCLUSIONS: Fundamental changes to residency training, all of which are associated with learner-centered education, can improve physicians' treatment of their patients with HIV and AIDS.

A persistent decline in the average tenure of medical school deans and a concern about the implications for medical school leadership led the Council of Deans of the Association of American Medical Colleges to commission the 1996-1997 study reported here. The author conducted open-ended interviews with a broad spectrum of 22 current and former deans, selected to achieve an appropriate distribution with regard to key characteristics of their schools and to assure the relevance of the findings to a broad range of settings. His in-depth analysis of the transcribed interviews, using standard qualitative techniques, was designed to illuminate the challenges confronting deans and suggest strategies to address them. The respondents consistently identified two forces in the health care environment that had had profound impacts on their role as deans and that frequently posed conflicts between the clinical and educational enterprises: a decline in the resources available to medical schools following an era of abundance, and unprecedented competition in the clinical arena. Analysis of their accounts of the problems they encountered in managing in this changed environment revealed several underlying sources: imbalance between the breadth of their responsibilities and their authority to manage; lack of clarity in the dean's mandate; inadequate institutional support for pursuing the missions of the school; insufficient attention to identifying requisite expertise and abilities for effective performance on the job as dean; and an anachronistic search process. The respondents offered numerous recommendations for addressing these problems, reflecting optimism about the prospects for purposeful change. While medical schools have unique features among educational institutions, the author concludes that the challenges that deans face and the strategies proposed for addressing them promise to have substantial relevance for academic leadership in other settings.

The impact of training on physicians' commitment to professional values is examined, using a cohort design to assess the evolution of attitudes toward AIDS during residency training. Cohorts of surgeons training in the same six residency programs were followed at key junctures, and their outlooks on three AIDS-related attitudes were examined: willingness to treat people with AIDS (PWAs), concern about exposure to HIV, and perceived benefits of treating AIDS. The findings revealed a consistent, negative impact of training on all three attitudes. Cohort and period (historical) effects were limited: younger cohorts more often viewed treating PWAs as a clinically valuable experience, and greater concern about exposure was evidenced as training progressed. The findings yield new evidence of the importance of residency training to professional socialization. More knowledge of alterable aspects of residency training that play a role is key to assuring that physicians emerge with a dedication to fulfilling their social responsibilities.

Understanding the impact of training on the development of physicians' attitudes toward AIDS is important to furthering our knowledge of the mechanisms through which socialization affects professional outlook, as well as promoting an adequate supply of providers to treat people with AIDS (PWAs). This prospective panel study collected data on 383 physicians at two critical stages: as fourth-year medical students and as third-year residents. Aspects of residency training (e.g., residents' morale and positive faculty role models) were the most powerful predictors of increase in willingness to treat PWAs. Decline in willingness was primarily a product of negative social attitudes-homophobia and IVDU-phobia (aversion to intravenous drug users). Cynicism toward patient care acted as a trigger, activating the negative effects of IVDU-phobia; having an acquaintance who is HIV positive mediated the negative impact of homophobia. Notably, cynicism was associated with basic aspects of training (specific characteristics of the faculty and of the educational milieu). The findings support a view of socialization as a pervasive process implicating intrinsic aspects of training and having an impact on a broad spectrum of outlooks. Accordingly, interventions must address structural characteristics that transcend AIDS-specific concerns.

A study of hospital patients with ischemic heart disease reports that patients in a public hospital received fewer needed diagnostic tests, surgeries, and follow-up visits for their conditions than their private hospital counterparts. Factors in the hospitals' organizational environments and the patients' social backgrounds were observed to have an impact on content of treatment and to affect patient as well as provider perspectives on the quality of care. To facilitate the analysis, data were collected from four sources: direct observation of the care of each patient on rounds and at the bedside; interviews with physicians concerning the rationale for their decisions; a process-oriented chart audit assessing the appropriateness of care; and an extensive home interview with each patient three months following hospital discharge to establish further use of health services, health status, and satisfaction with care.

Physicians' responses to AIDS at different career stages and in different specialties were studied by surveying house staff (N = 438), faculty (N = 363), and applicants (N = 487) at six residency programs in internal medicine and six in surgery. House staff had more negative outlooks than senior medical students and faculty, reporting greater fear of exposure to AIDS and greater unwillingness to treat AIDS patients. Surgeons were more negative than internists on these dimensions. For all groups, concern about possible negative educational consequences of treating AIDS patients was largely a function of their amount of contact with AIDS patients. Comparing willingness to treat AIDS and nine other conditions, AIDS consistently ranked low, along with Alzheimer's disease, alcoholism, and drug dependency. The findings have practical implications for hospitals and training programs. In addition, they raise issues concerning the impact of training on professional socialization, and call into question physicians' commitment to the professional norm of treating all patients regardless of provider self-interest, patient social characteristics, or medical uncertainty.

To assess the impact of social factors on the content of care, panels of patients with ischemic heart disease at a public and its affiliated voluntary hospital were followed up through their acute hospitalizations and 3 months after discharge. Data were collected from firsthand observation of rounds, chart review, and a 3-month patient follow-up survey. Among patients for whom cardiac catheterization was indicated, 100% from the voluntary hospital underwent this procedure compared with 41% from the public institution. For patients for whom exercise stress testing was indicated, 90% from the voluntary hospital compared with 50% from the public institution underwent the procedure. Factors observed to contribute to these patterns emanated from the hospital setting as well as from the patients' social environment, including difficulties in arranging transfers for procedures, obstacles to coordinating inpatient and ambulatory care, and patient problems in keeping outpatient appointments. ( Arch Intern Med . 1992;152:595-600)