Community College Pathways to Medical School and Family Medicine Residency Training

PURPOSE

Medical students who attend community college are more likely to express intention to train in family medicine. This study examined whether community college attendance is associated with family medicine residency training in a national sample of US medical school graduates.

METHODS

We performed a cross-sectional analysis using the Association of American Medical Colleges matriculant files of residency trainees who graduated from medical school between 2010 to 2012. Residency specialty (family medicine vs other) was modeled using logistic regression analysis; the key independent variable was community college attendance, with categories of non-community college (reference); community college while in high school; community college after graduating from high school, then transfer to 4-year university; and community college after graduating from a 4-year university or as a postbaccalaureate. The logistic model adjusted for age, sex, race/ethnicity, years in medical school, parental education (a marker of socioeconomic status), and high school US region.

RESULTS

Of the 43,382 medical school graduates studied, 25.9% attended community college and 8.7% trained in family medicine. In unadjusted analysis, graduates attending community college while in high school, after graduating from high school with transfer to 4-year university, or after graduating from a 4-year university or as a postbaccalaureate (12.0%, 12.7%, and 10.8%, respectively) were more likely to train in family medicine compared with their peers who did not attend community college (7.7%). Respective adjusted odds ratios were 1.47 (95% CI, 1.33-1.63; P <.001), 1.27 (95% CI, 1.06-1.52; P = .009), and 1.17 (95% CI, 1.06-2.29; P = .002). Among family medicine residents, 32.7% of those who were white, 35.2% of those Asian, 50.8% of those Latino, and 32.7% of those black or African American attended community college.

CONCLUSIONS

US medical school graduates who attended community college were more likely to train in family medicine, suggesting community college is an important pathway for increasing the primary care workforce.

Familial aggregation of major depressive disorder in an African-American community

BACKGROUND

African Americans (AAs) with major depressive disorder (MDD) experience more impairment and poorer treatment outcomes relative to Whites, yet are underrepresented in family studies of MDD. This is the first study to investigate the familial aggregation of major depression among AAs.

METHODS

Participants' reports of depression from clinical and family history (FH) interviews were used to examine depression rates among 435 first-degree relatives and half-siblings of 63 depressed cases and 222 relatives of 33 nondepressed controls. Binary logistic regression was used to compute odds ratios (ORs) for FH of MDD and level of trauma exposure (high and low) in cases versus controls. Poisson regression models with generalized estimating equations were used to assess MDD in relatives of cases versus relatives of controls.

RESULTS

Cases and controls did not differ in either FH of MDD (OR = 1.2, 95% confidence interval [CI] = 0.5-2.9), or prevalence of MDD in relatives (relative risk [RR] = 1.5, 95% CI = 0.8-2.5). However, exposure to high trauma was associated with increased risk of MDD (OR = 3.0, 95% CI = 1.22-7.17) and the combined effect of FH and trauma was greater than expected under an additive model. Similarly, the RR for MDD among relatives of cases with high-trauma levels was 2.2 (1.24-4.2), compared to relatives of controls with low trauma.

CONCLUSION

The effect of FH of MDD appears to be exacerbated among individuals exposed to high trauma. Replication and further research on the chronology and subtypes of trauma and MDD, and their interactions, remain essential in AA populations.

Toward a Comprehensive Understanding of Intergroup Contact: Descriptions and Mediators of Positive and Negative Contact Among Majority and Minority Groups

Positive contact predicts reduced prejudice, but negative contact may increase prejudice at a stronger rate. The current project builds on this work in four ways: establishing an understanding of contact that is grounded in subjective experience, examining the affective mediators involved in the negative contact-prejudice relationship, extending research on the effects of positive and negative contact to minority groups, and examining the contact asymmetry experimentally. Study 1 introduced anger as a mediator of the relationships between positive and negative contact and prejudice among White Americans ( N = 371), using a contact measure that reflected the frequency and intensity of a wide range of experiences. Study 2 found a contact asymmetry among Black and Hispanic Americans ( N = 365). Study 3 found initial experimental evidence of a contact asymmetry ( N = 309). We conclude by calling for a more nuanced understanding of intergroup contact that recognizes its multifaceted and subjective nature.

Disparities in oral health by immigration status in the United States

BACKGROUND

Few investigators have explored differences in oral health status between immigrants and natives. To address this gap, the authors used nationally representative data to characterize disparities in oral health among noncitizens, naturalized citizens, and native adults.

METHODS

The 2013 to 2014 National Health and Nutrition Examination Survey, a nationally representative in-person survey, provides oral health data for US natives, naturalized citizens, and noncitizens. Univariate and multivariate regression analyses were conducted to compare evidence of caries and periodontal disease, as well as recommendations for oral health care, stratified by immigration status for adults.

RESULTS

More than one-half of noncitizens (50.5%) received a diagnosis of periodontal disease, and 38.0% had caries; for natives, these rates were 34.4% and 27.0%, respectively. Differences between natives and naturalized citizens were not statistically significant. After adjusting for age, sex, race or ethnicity, education, poverty, tobacco smoking status, and number of permanent teeth, noncitizens still had 45% higher adjusted odds of periodontal disease and 60% higher odds of receiving recommendations for oral health care than natives. However, differences between noncitizens and natives were no longer important after adjusting for insurance.

CONCLUSIONS

Noncitizen immigrants reported having substantially poorer oral health than natives in the United States. However, disparities between noncitizens and natives are no longer important when accounting for health insurance.

PRACTICAL IMPLICATIONS

Although noncitizen adults have a higher likelihood of poor oral health than native adults, having insurance may close this gap. Health care reform initiatives should provide dental benefits for adults to help mitigate the current economic and legal barriers that many immigrants face when accessing oral health care.

Improving the effectiveness of interpreted consultations: Australian interpreter, general practitioner and patient perspectives

Healthcare consultations with patients lacking English proficiency are challenging for all parties, even in Australian primary care where the engagement of interpreters is encouraged and fully subsidised. Our objective was to understand these challenges from the perspectives of interpreters, patients and general practitioners in order to improve the effectiveness of interpreted consultations. Our investigator team approached the interpreted consultation as an interprofessional collaboration. A convenience sample of seven general practitioners, eight health interpreters and six representatives from culturally and linguistically diverse communities (representing the patient perspective) participated in three separate focus group discussions, lasting 60-90 min each, exploring participant experiences with healthcare consultations in which interpreters were present. Two semistructured interviews were undertaken subsequently with three additional community representatives purposively recruited to increase participant diversity. Data were collected in 2016 and analysed inductively using a method of constant comparison to identify, and reach consensus on, key emerging themes. All participant groups emphasised the importance of working with trained interpreters, rather than relying on family interpreters or a doctor's own second language skills. Although participants reported experiences of effective interpreted consultations, other reports suggested that some doctors are unaware of, or have difficulty following, accepted guidelines about speech, gaze and turn-taking. Challenges identified in relation to interpreted consultations fell into the five themes of contextual constraints, consultation complexity, communication difficulties, the interpreter role and collaboration. Some general practitioner participants appeared to be unsure and anxious about the etiquette of interpreted consultations, and there was some confusion between and within participant groups about interpreter roles and professional codes. A briefing session prior to the consultation, clarifying the roles of all parties, including any family or bicultural workers present, may help to establish respectful, flexible and effective interprofessional collaborations and to encourage participants to directly address any problems during the consultation.

The Harold Amos Medical Faculty Development Program: Evaluation of a National Program to Promote Faculty Diversity and Health Equity

Purpose: The Harold Amos Medical Faculty Development Program (AMFDP), a national program of the Robert Wood Johnson Foundation, seeks to support academic physicians from historically disadvantaged backgrounds and serves as a model program for promoting faculty diversity and health equity. Our objective was to determine differences in scientific productivity, promotions and retentions, and leadership attainment among faculty applicants to this national minority faculty development program.

Methods: Final-round interview applicants from 2003 to 2008 were selected. Differences in publications, grants, promotions/retentions, and leadership positions through 2013 were compared between funded scholars and unfunded nonscholars. Semistructured interviews were conducted to identify factors that facilitated and hindered academic success.

Results: A total of 124 applicants (76 scholars and 48 nonscholars) who participated in final-round interviews from 2003 to 2008 were eligible. Scholars and nonscholars had similar number of publications. Scholars had greater number of grants and grant dollars, but differences were not significant after accounting for AMFDP program awards. Scholars were more likely to hold leadership positions (28% vs. 10%, p=0.02), but equally likely to be promoted (67% vs. 58%, p=0.32) and retained (84% vs. 75%, p=0.21). In interviews, all participants endorsed mentoring, funding, and nonscientific education to academic success, but scholars reported greater availability of leadership opportunities consequent to AMFDP.

Conclusion: There were few differences in academic productivity attributable to a national faculty diversity program. However, program participants were more likely to endorse and attain leadership positions. Academic institutions should consider facilitating leadership development of minority faculty as a means of advancing health equity research and training.

Substance Use Prevention Programs for Indigenous Adolescents in the United States of America, Canada, Australia and New Zealand: Protocol for a Systematic Review

BACKGROUND

Indigenous adolescents are at a higher risk of experiencing harms related to substance use compared with their non-Indigenous counterparts as a consequence of earlier onset and higher rates of substance use. Early onset of substance use has been identified as a risk factor for future substance use problems and other health, social, and family outcomes. Therefore, prevention of substance use among adolescents has been identified as a key area to improve health of Indigenous Peoples. Evidence exists for the effectiveness of prevention approaches for adolescents in mainstream populations and, most recently, for the use of computer- and Internet-delivered interventions to overcome barriers to implementation. However, there is currently no conclusive evidence about the effectiveness of these approaches for Indigenous adolescents.

OBJECTIVE

The purpose of this review is to synthesize the international evidence regarding the effectiveness of substance use prevention programs for Indigenous adolescents in the United States, Canada, Australia, and New Zealand.

METHODS

A total of 8 peer-reviewed databases and 20 gray literature databases will be searched, using search terms in line with the aims of this review and based on previous relevant reviews of substance use prevention. Studies will be included if they evaluate a substance use prevention program with Indigenous adolescents (aged 10 to 19 years) as the primary participant group and are published between January 1, 1990 and August 31, 2017.

RESULTS

A narrative synthesis will be provided about the effectiveness of the programs, the type of program (whether culture-based, adapted, or unadapted), delivery of the program (computer- and Internet-delivered or traditional), and the setting in which the programs are delivered (community, school, family, clinical, or a combination).

CONCLUSIONS

The study will identify core elements of effective substance use prevention programs among Indigenous adolescents and appraise the methodological quality of the studies. This review will provide researchers, policy makers, and program developers with evidence about the potential use of prevention approaches for Indigenous adolescents.

Comparison of the HEI and HEI-2010 Diet Quality Measures in Association with Chronic Disease Risk among Low-Income, African American Urban Youth in Baltimore, Maryland

OBJECTIVE

Overall diet patterns may be a better predictor of disease risk than specific nutrients or individual foods. The purpose of this study is to examine how overall diet patterns relate to nutritional intake, body composition, and physiological measures of chronic disease risk among low-income, urban African American adolescents.

METHODS

Cross-sectional data were collected from two samples of African American adolescents (n = 317) from a low-income urban community, including dietary intake using the food frequency Youth/Adolescent Questionnaire and anthropometric measures. Serum cholesterol, serum lipoproteins, and glucose tolerance were measured in a subsample. Means testing compared differences in Healthy Eating Index (HEI) and Healthy Eating Index-2010 (HEI-2010) component and total scores. Pearson correlations examined how HEI and HEI-2010 scores related to nutrient, food intakes, and markers of disease risk, including body mass index, percent body fat, abdominal fat, serum cholesterol, serum lipoproteins, and impaired glucose tolerance. Fisher R-Z transformations compared magnitude differences between HEI and HEI-2010 correlations to nutritional intake and chronic disease risk.

RESULTS

Both HEI and HEI-2010 scores were positively associated with micronutrient intakes. Higher HEI scores were inversely related to serum cholesterol, low-density lipoprotein, impaired glucose tolerance, percent body fat, and percent abdominal fat. HEI-2010 scores were not related to biomarkers of chronic disease risk.

CONCLUSIONS

Compared to the HEI-2010, the HEI is a better indicator of chronic disease risk among low-income, urban African American adolescents.

A decline in depression treatment following FDA antidepressant warnings largely explains racial/ethnic disparities in prescription fills

BACKGROUND

The Food and Drug Administration's 2004 antidepressant warning was followed by decreases in antidepressant prescribing for youth. This was due to declines in all types of depression treatment, not just the intended changes in antidepressant prescribing patterns. Little is known about how these patterns varied by race/ethnicity.

METHOD

Data are Medicaid claims from four U.S. states (2002-2009) for youth ages 5-17. Interrupted time series analyses measured changes due to the warning in levels and trends, by race/ethnicity, of three outcomes: antidepressant prescription fills, depression treatment visits, and incident fluoxetine prescription fills.

RESULTS

Prewarning, antidepressant fills were increasing across all racial/ethnic groups, fastest for White youth. Postwarning, there was an immediate drop and continued decline in the rate of fills among White youth, more than double the decline in the rate among Black and Latino youth. Prewarning, depression treatment visits were increasing for White and Latino youth. Postwarning, depression treatment stabilized among Latinos, but declined among White youth. Prewarning, incident fluoxetine fills were increasing for all groups. Postwarning, immediate increases and increasing trends of fluoxetine fills were identified for all groups.

CONCLUSIONS

Antidepressant prescription fills declined most postwarning for White youth, suggesting that risk information may have diffused less rapidly to prescribers or caregivers of minorities. Decreases in depression treatment visits help to explain the declines in antidepressant prescribing and were largest for White youth. An increase in incident fluoxetine fills, the only medication indicated for pediatric depression at the time, suggests that the warning may have shifted prescribing practices.

Technology Components as Adjuncts to Family-Based Pediatric Obesity Treatment in Low-Income Minority Youth

BACKGROUND

Strategies to treat pediatric obesity are needed, especially among high-need populations. Technology is an innovative approach; however, data on technology as adjuncts to in-person treatment programs are limited.

METHODS

A total of 64 children [body mass index (BMI) ≥85th percentile, mean age = 9.6 ± 3.1 years, 32.8% female, 84.4% Hispanic] were recruited to participate in one of three cohorts of a family-based behavioral group (FBBG) treatment program: FBBG only, TECH1, and TECH2. Rolling, nonrandomized recruitment was used to enroll participants into three cohorts from May 2014 to February 2015. FBBG began in May 2014 and received the standard, in-person 12-week treatment only (n = 21); TECH1 began in September 2014 and received FBBG plus a digital tablet equipped with a fitness app (FITNET) (n = 20); TECH2 began in February 2015 and received FBBG and FITNET, plus five individually tailored TeleMed health-coaching sessions delivered via Skype (n = 23). Child BMI z-score (BMI-z) was assessed at baseline and postintervention. Secondary aims examined weekly FBBG attendance, feasibility/acceptability of FITNET and Skype, and the effect of technology engagement on BMI-z.

RESULTS

FBBG and TECH1 participants did not show significant reductions in BMI-z postintervention [FBBG: β = -0.05(0.04), p = 0.25; TECH1: β = -0.006(0.06), p = 0.92], but TECH2 participants did [β = -0.09(0.02), p < 0.001] and TeleMed session participation was significantly associated with BMI-z reduction [β = -0.04(0.01), p = 0.01]. FITNET use and FBBG attendance were not associated with BMI-z in any cohort. Overall, participants rated the technology as highly acceptable.

CONCLUSIONS

Technology adjuncts are feasible, used by hard-to-reach participants, and show promise for improving child weight status in obesity treatment programs.

"You Get Beautiful Teeth Down There": Racial/Ethnic Minority Older Adults' Perspectives on Care at Dental School Clinics

To help eliminate reported racial/ethnic and socioeconomic inequities in oral health care, listening to the perspectives of racial/ethnic minority older adults on their experiences with dental school clinics is needed. The aim of this study was to examine the experiences of African American, Puerto Rican, and Dominican older adults who attend senior centers in upper Manhattan, New York City, regarding the care received at dental school clinics. Focus groups were conducted from 2013 to 2015 with 194 racial/ethnic minority men and women aged 50 years and older living in upper Manhattan. All of the 24 focus group sessions were digitally audiorecorded and transcribed for analysis. Groups conducted in Spanish were transcribed first in Spanish and then translated into English. Analysis of the transcripts was conducted using thematic content analysis. Seven subthemes were manifest in the data related to these adults' positive experiences with dental school clinics: excellent outcomes and dentists, painless and safe treatment, affordable care, honest and reputable, benefits of student training, accepting and helpful, and recommended by family and friends. Negative experiences centered around four subthemes: multiple visits required for treatment, loss of interpersonal communication due to use of technology, inconvenient location, and perceived stigma with Medicaid. This study provided novel evidence of the largely positive experiences with dental schools of racial/ethnic minority senior center attendees. Interventions targeted at the organization and provider level, including organizational motivation, resources, staff attributes, climate, and teamwork plus payment programs and services, insurance and affordability, and provider- and system-level supports, may improve health care processes and patient experiences of care.

Contribution of short sleep duration to ethnic differences in cardiovascular disease: results from a cohort study in the Netherlands

OBJECTIVES

We analysed association between short sleep duration and prevalence of cardiovascular disease (CVD) in a multiethnic population living in the Netherlands, and the contribution of short sleep to the observed ethnic differences in the prevalence of CVD, independent of CVD risk factors.

METHODS

20 730 participants (aged 18-71 years) of the HELIUS (Healthy Life in an Urban Setting) Study were investigated. Self-reported sleep duration was classified as: short (<7 hours/night) and healthy (7-9 hours/night). Prevalence of CVD was assessed using the Rose Questionnaire on angina pectoris, intermittent claudication and possible myocardial infarction. Association of short sleep duration with prevalent CVD and the contribution of short sleep to the observed ethnic differences in the prevalence of CVD were analysed using adjusted prevalence ratio(s) (PRs) with 95% CI.

RESULTS

Results indicate that short sleep was associated with CVD among all ethnic groups with PRs ranging from 1.44 (95% CI 1.20 to 1.71) in Moroccans to 1.74 (95% CI 1.28 to 2.36) in Dutch after adjustment for age, sex and conventional CVD risk factors. The independent contributions of short sleep (in percentage) to ethnic differences in CVD compared with Dutch were 12%, 16%, 6%, 19% and 6% in South-Asian Surinamese, African-Surinamese, Ghanaian, Turkish and Moroccan, respectively.

CONCLUSION

Short sleep contributed to ethnic differences in CVD independent of well-known CVD risk factors particularly in Surinamese and Ghanaian groups. Reducing sleep deprivation may be a relevant entry point for reducing increased CVD risks among the various ethnic minority groups.

Minorities Are Underrepresented in Clinical Trials of Pharmaceutical Agents for Cystic Fibrosis

RATIONALE

Members of racial or ethnic minorities make up an appreciable proportion of patients with cystic fibrosis (CF) and have worse outcomes than non-Latino white individuals. Between 1,999 and 2014, the CF Foundation Patient Registry reported an increase in minorities from 5 to 8.2% for Latinos, from 3 to 4.6% for black individuals and from 1.4 to 3.1% for "Other."

OBJECTIVES

To evaluate the representation of racial and ethnic minorities in pharmacology clinical trials for CF.

METHODS

We analyzed pharmacology clinical trials in CF published between 1999 and 2015 by searching PubMed and published study reference lists for qualifying study reports. We examined whether the race and ethnicity of study subjects were reported and, if so, what percentage of subjects represented major minority groups.

MEASUREMENTS AND MAIN RESULTS

Among 147 pharmacology clinical trials, only 19.7% reported the race or ethnicity of study subjects. Latinos were verified as included in 7.5% of clinical trials, black individuals in 6.8%, and Asians in 2.0%. Inclusion of subjects described as "Other race" was reported in 7.5% of trials. In 29 clinical trials that reported race and ethnicity, the percentage of minorities included as subjects was 2.0% for Latinos, 1.0% for black individuals, and 0.1% for Asians.

CONCLUSIONS

Although CF disproportionately affects non-Latino white individuals, members of other racial or ethnic groups are proportionally underrepresented in CF pharmacology clinical trials. Inadequate inclusion of minorities and failure to report the racial or ethnic background of study subjects limits information about factors influencing drug response and may contribute to health disparities for minorities with CF.

Show me the money! An analysis of underserved stakeholders' funding priorities in Patient Centered Outcomes Research domains

AIM

Develop an accessible exercise to engage underserved populations about research funding priorities; analyze the criteria they use to prioritize research; contrast these criteria to those currently used by Patient Centered Outcomes Research Institute (PCORI).

MATERIALS & METHODS

Academic and community partners collaborated to develop an Ipad exercise to facilitate group deliberation about PCOR funding priorities. 16 groups (n = 183) of underserved individuals in both urban and rural areas participated. Recordings were qualitatively analyzed for prioritization criteria.

RESULTS

Analysis yielded ten codes, many of which were similar to PCORI criteria, but all of which challenged or illuminated these criteria.

CONCLUSION

Directly involving underserved populations in determining funding criteria is both feasible and important, and can better fulfill PCORI's goal of incorporating patient priorities.

Challenges of Dental Assisting Students in Their Pursuit of Academic Success

The aim of this study was to identify the challenges encountered by dental assisting students, especially those from underrepresented racial and ethnic groups (UREG), that affected their achieving academic success. In 2016, directors of the nine northern California dental assisting programs were contacted via email to explain the study and request an opportunity to administer the 26-item survey to their currently enrolled students. Student responses were entered into a survey research program, which tabulated the data and calculated the frequency of responses to each item. All nine programs participated, and the overall student response rate was 98%. Most (71%) of the 215 respondents agreed that they had experienced challenges in achieving academic success. Respondents reported the following challenges that made it difficult to perform well at school: financial responsibilities (41%), family responsibilities (33%), and language challenges (21%). These challenges, as well as difficulty understanding the language and vocabulary of instructional materials and cost of tuition and supplies, were statistically related to respondents' perceptions of their challenges to academic success. Most (83%) of the respondents perceived that faculty members supported their academic success. One-third of the respondents were from UREG: Hispanic, African American, and Native American. Higher percentages of UREG than non-UREG participants worked more hours/week (p=0.03) and tended to perceive financial (52%/32%) and family (42%/28%) responsibilities as challenges. Since both UREG and non-UREG respondents experienced these challenges, all students should be informed of institutional and programmatic resources that can assist them in achieving academic success.

Understanding advance care planning within the South Asian community

Background

Advance care planning (ACP) is a process of reflection on and communication of a person's future health‐care preferences. Evidence suggests visible minorities engage less in ACP. The South Asian ethnic group is the largest visible minority group in Canada, and information is needed to understand how ACP is perceived and how best to approach ACP within this diverse community.

Objective

To explore perspectives of South Asian community members towards ACP.

Design

Peer‐to‐peer inquiry. South Asian community members who graduated from the Patient and Community Engagement Research programme (PaCER) at the University of Calgary utilized the PaCER method (SET, COLLECT and REFLECT) to conduct a focus group, family interviews and a community forum.

Setting and participants

Fifty‐seven community‐dwelling men and women (22‐86 years) who self‐identified with the South Asian community in Calgary, Alberta, Canada.

Results

The concept of ACP was mostly foreign to this community and was often associated with other end‐of‐life issues such as organ donation and estate planning. Cultural aspects (e.g. trust in shared family decision making and taboos related to discussing death), religious beliefs (e.g. fatalism) and immigration challenges (e.g. essential priorities) emerged as barriers to participation in ACP. However, participants were eager to learn about ACP and recommended several engagement strategies (e.g. disseminate information through religious institutions and community centres, include families in ACP discussions, encourage family physicians to initiate discussions and translate materials).

Conclusions

Use of a patient engagement research model proved highly successful in understanding South Asian community members' participation in ACP.

What Are We Doing? A Survey of United States Nephrology Fellowship Program Directors

Interest in nephrology has been declining in recent years. Long work hours and a poor work/life balance may be partially responsible, and may also affect a fellowship's educational mission. We surveyed nephrology program directors using a web-based survey in order to define current clinical and educational practice patterns and identify areas for improvement. Our survey explored fellowship program demographics, fellows' workload, call structure, and education. Program directors were asked to estimate the average and maximum number of patients on each of their inpatient services, the number of patients seen by fellows in clinic, and to provide details regarding their overnight and weekend call. In addition, we asked about number of and composition of didactic conferences. Sixty-eight out of 148 program directors responded to the survey (46%). The average number of fellows per program was approximately seven. The busiest inpatient services had a mean of 21.5±5.9 patients on average and 33.8±10.7 at their maximum. The second busiest services had an average and maximum of 15.6±6.0 and 24.5±10.8 patients, respectively. Transplant-only services had fewer patients than other service compositions. A minority of services (14.5%) employed physician extenders. Fellows most commonly see patients during a single weekly continuity clinic, with a typical fellow-to-faculty ratio of 2:1. The majority of programs do not alter outpatient responsibilities during inpatient service time. Most programs (approximately 75%) divided overnight and weekend call responsibilities equally between first year and more senior fellows. Educational practices varied widely between programs. Our survey underscores the large variety in workload, practice patterns, and didactics at different institutions and provides a framework to help improve the service/education balance in nephrology fellowships.

Targeted mass media interventions promoting healthy behaviours to reduce risk of non-communicable diseases in adult, ethnic minorities

BACKGROUND

Physical activity, a balanced diet, avoidance of tobacco exposure, and limited alcohol consumption may reduce morbidity and mortality from non-communicable diseases (NCDs). Mass media interventions are commonly used to encourage healthier behaviours in population groups. It is unclear whether targeted mass media interventions for ethnic minority groups are more or less effective in changing behaviours than those developed for the general population.

OBJECTIVES

To determine the effects of mass media interventions targeting adult ethnic minorities with messages about physical activity, dietary patterns, tobacco use or alcohol consumption to reduce the risk of NCDs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, ERIC, SweMed+, and ISI Web of Science until August 2016. We also searched for grey literature in OpenGrey, Grey Literature Report, Eldis, and two relevant websites until October 2016. The searches were not restricted by language.

SELECTION CRITERIA

We searched for individual and cluster-randomised controlled trials, controlled before-and-after studies (CBA) and interrupted time series studies (ITS). Relevant interventions promoted healthier behaviours related to physical activity, dietary patterns, tobacco use or alcohol consumption; were disseminated via mass media channels; and targeted ethnic minority groups. The population of interest comprised adults (≥ 18 years) from ethnic minority groups in the focal countries. Primary outcomes included indicators of behavioural change, self-reported behavioural change and knowledge and attitudes towards change. Secondary outcomes were the use of health promotion services and costs related to the project.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the references to identify studies for inclusion. We extracted data and assessed the risk of bias in all included studies. We did not pool the results due to heterogeneity in comparisons made, outcomes, and study designs. We describe the results narratively and present them in 'Summary of findings' tables. We judged the quality of the evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology.

MAIN RESULTS

Six studies met the inclusion criteria, including three RCTs, two cluster-RCTs and one ITS. All were conducted in the USA and comprised targeted mass media interventions for people of African descent (four studies), Spanish-language dominant Latino immigrants (one study), and Chinese immigrants (one study). The two latter studies offered the intervention in the participants' first language (Spanish, Cantonese, or Mandarin). Three interventions targeted towards women only, one pregnant women specifically. We judged all studies as being at unclear risk of bias in at least one domain and three studies as being at high risk of bias in at least one domain.We categorised the findings into three comparisons. The first comparison examined mass media interventions targeted at ethnic minorities versus an equivalent mass media intervention intended for the general population. The one study in this category (255 participants of African decent) found little or no difference in effect on self-reported behavioural change for smoking and only small differences in attitudes to change between participants who were given a culturally specific smoking cessation booklet versus a booklet intended for the general population. We are uncertain about the effect estimates, as assessed by the GRADE methodology (very low quality evidence of effect). No study provided data for indicators of behavioural change or adverse effects.The second comparison assessed targeted mass media interventions versus no intervention. One study (154 participants of African decent) reported effects for our primary outcomes. Participants in the intervention group had access to 12 one-hour live programmes on cable TV and received print material over three months regarding nutrition and physical activity to improve health and weight control. Change in body mass index (BMI) was comparable between groups 12 months after the baseline (low quality evidence). Scores on a food habits (fat behaviours) and total leisure activity scores changed favourably for the intervention group (very low quality evidence). Two other studies exposed entire populations in geographical areas to radio advertisements targeted towards African American communities. Authors presented effects on two of our secondary outcomes, use of health promotion services and project costs. The campaign message was to call smoking quit lines. The outcome was the number of calls received. After one year, one study reported 18 calls per estimated 10,000 targeted smokers from the intervention communities (estimated target population 310,500 persons), compared to 0.2 calls per estimated 10,000 targeted smokers from the control communities (estimated target population 331,400 persons) (moderate quality evidence). The ITS study also reported an increase in the number of calls from the target population during campaigns (low quality evidence). The proportion of African American callers increased in both studies (low to very low quality evidence). No study provided data on knowledge and attitudes for change and adverse effects. Information on costs were sparse.The third comparison assessed targeted mass media interventions versus a mass media intervention plus personalised content. Findings are based on three studies (1361 participants). Participants in these comparison groups received personal feedback. Two of the studies recorded weight changes over time. Neither found significant differences between the groups (low quality evidence). Evidence on behavioural changes, and knowledge and attitudes typically found some effects in favour of receiving personalised content or no significant differences between groups (very low quality evidence). No study provided data on adverse effects. Information on costs were sparse.

AUTHORS' CONCLUSIONS

The available evidence is inadequate for understanding whether mass media interventions targeted toward ethnic minority populations are more effective in changing health behaviours than mass media interventions intended for the population at large. When compared to no intervention, a targeted mass media intervention may increase the number of calls to smoking quit line, but the effect on health behaviours is unclear. These studies could not distinguish the impact of different components, for instance the effect of hearing a message regarding behavioural change, the cultural adaptation to the ethnic minority group, or increase reach to the target group through more appropriate mass media channels. New studies should explore targeted interventions for ethnic minorities with a first language other than the dominant language in their resident country, as well as directly compare targeted versus general population mass media interventions.

A successful approach to minimizing attrition in racial/ethnic minority, low-income populations

BACKGROUND

Recruiting and retaining minority participants in clinical trials continue to be major challenges. Although multiple studies document lower minority trial enrollment, much less is known about effective minority retention strategies. Our objectives were to evaluate an innovative approach to high RCT retention of minority children, and identify child/caregiver characteristics predicting attrition.

METHODS

The Kids' HELP trial examined the effects of Parent Mentors on insuring uninsured minority children. We tested a retention strategic framework consisting of: 1) optimizing cultural/linguistic competency; 2) staff training on participant relationships and trust; 3) comprehensive participant contact information; 4) an electronic tracking database; 5) reminders for upcoming outcomes-assessment appointments; 6) frequent, sustained contact attempts for non-respondents; 7) financial incentives; 8) individualized rapid-cycle quality-improvement approaches to non-respondents; 9) reinforcing study importance; and 10) home assessment visits. We compared attrition in Kids' HELP vs. two previous RCTs in similar populations, and conducted bivariate and multivariable analyses of factors associated with Kids' HELP attrition.

RESULTS

Attrition in Kids' HELP was lower than in two similar RCTs, at 10.9% vs. 37% and 40% (P <0.001). After multivariable adjustment, missing the first outcomes follow-up assessment was the only factor significantly associated with attrition (relative risk=1.5; 95% confidence interval, 1.1-2.0).

CONCLUSIONS

A retention strategic framework was successful in minimizing attrition in minority, low-income children. Participants missing first assessment appointments were at highest risk of subsequent attrition. These findings suggest that deploying this framework may help RCT retention of low-income minority children, particularly those at the highest risk of subsequent attrition.

Closing achievement gaps with a utility-value intervention: Disentangling race and social class

Many college students abandon their goal of completing a degree in science, technology, engineering, or math (STEM) when confronted with challenging introductory-level science courses. In the U.S., this trend is more pronounced for underrepresented minority (URM) and first-generation (FG) students, and contributes to persisting racial and social-class achievement gaps in higher education. Previous intervention studies have focused exclusively on race or social class, but have not examined how the 2 may be confounded and interact. This research therefore investigates the independent and interactive effects of race and social class as moderators of an intervention designed to promote performance, measured by grade in the course. In a double-blind randomized experiment conducted over 4 semesters of an introductory biology course (N = 1,040), we tested the effectiveness of a utility-value intervention in which students wrote about the personal relevance of course material. The utility-value intervention was successful in reducing the achievement gap for FG-URM students by 61%: the performance gap for FG-URM students, relative to continuing generation (CG)-Majority students, was large in the control condition, .84 grade points (d = .98), and the treatment effect for FG-URM students was .51 grade points (d = 0.55). The UV intervention helped students from all groups find utility value in the course content, and mediation analyses showed that the process of writing about utility value was particularly powerful for FG-URM students. Results highlight the importance of intersectionality in examining the independent and interactive effects of race and social class when evaluating interventions to close achievement gaps and the mechanisms through which they may operate. (PsycINFO Database Record

Race/ethnic comparisons of waist-to-height ratio for cardiometabolic screening: The study of women's health across the nation

OBJECTIVE

To compare the performance of waist-to-height ratio as a screening tool for cardiometabolic conditions - hypertension, prediabetes/diabetes, dyslipidemia, and subclinical inflammation - in 5 race/ethnic groups of mid-life women.

METHODS

Waist-to-height ratio and 4 cardiometabolic conditions were assessed in 3033 premenopausal midlife women (249 Hispanic, 226 Chinese, 262 Japanese, 1435 European-American, and 861 African American). The areas under the receiver operating characteristic curve (AUROC) were compared across the five race/ethnic groups using waist-to-height ratio to determine the likelihood of the four cardiometabolic conditions.

RESULTS

The performance of waist-to-height ratio to detect one or more cardiometabolic conditions was comparable among all race/ethnic groups (AUROC > 0.60, p = 0.252), and was good/fair (AUROC > 0.60) when hypertension, prediabetes/diabetes, dyslipidemia, or subclinical inflammation were analyzed separately. The performance of waist-to-height ratio of 0.50 was skewed towards higher specificity among groups with low prevalence of cardiometabolic conditions and lower median waist-to-height ratio, and towards higher sensitivity among groups with high prevalence of cardiometabolic conditions and higher median waist-to-height ratio.

CONCLUSIONS

Waist-to-height ratio can be used for community-based screening of mid-life women who may need secondary prevention for cardiometabolic conditions. A simple public health message: "Keep your waist to less than half of your height" applies to midlife women.

Retention strategies for health disparities preventive trials: findings from the Early Childhood Caries Collaborating Centers

OBJECTIVES

To identify successful strategies for retention of participants in multiyear, community-based randomized controlled trials (RCTs) aiming to reduce early childhood caries in health disparities populations from diverse racial/ethnic backgrounds and across diverse geographic settings.

METHODS

Four RCTs conducted by the Early Childhood Caries Collaborating Centers (EC4), an initiative of the National Institute of Dental and Craniofacial Research, systematically collected information on the success of various strategies implemented to promote participant retention in each RCT. The observational findings from this case series of four RCTs were tabulated and the strategies rated by study staff.

RESULTS

Participant retention at 12 months of follow-up ranged from 52.8 percent to 91.7 percent, and at 24 months ranged from 53.6 percent to 85.9, across the four RCTs. For the three RCTs that had a 36-month follow-up, retention ranged from 53.6 percent to 85.1 percent. Effectiveness of different participant retention strategies varied widely across the RCTs.

CONCLUSIONS

Findings from this case series study may help to guide the design of future RCTs to maximize retention of study participants and yield needed data on effective interventions to reduce oral health disparities.

A health care navigation tool assesses asthma self-management and health literacy

BACKGROUND

Self-management of moderate-to-severe asthma depends on the patient's ability to (1) navigate (access health care to obtain diagnoses and treatment), (2) use inhaled corticosteroids (ICSs) properly, and (3) understand ICS function.

OBJECTIVE

We sought to test whether navigation skills (medication recall, knowledge of copay requirements, and ability to provide information needed for a medical visit about a persistent cough unresponsive to medication) are related to other self-management skills and health literacy.

METHODS

A 21-item Navigating Ability (NAV2) questionnaire was developed, validated, and then read to adults with moderate-to-severe asthma. ICS technique was evaluated by using scales derived from instructions in national guidelines; knowledge of ICS function was evaluated by using a validated 10-item questionnaire. Spearman correlation was computed between NAV2 score and these questionnaires and with numeracy (Asthma Numeracy Questionnaire) and print literacy (Short Test of Functional Health Literacy in Adults).

RESULTS

Two hundred fifty adults participated: age, 51 ± 13 years; 72% female; 65% African American; 10% Latino; 50% with household income of less than $30,000/y; 47% with no more than a 12th-grade education; and 29% experienced hospitalizations for asthma in the prior year. A higher NAV2 score was associated with correct ICS technique (ρ = 0.24, P = .0002), knowledge of ICSs (ρ = 0.35, P < .001), better print literacy (ρ = 0.44, P < .001), and numeracy (ρ = 0.41, P < .001).

CONCLUSIONS

Patients with poor navigational ability are likely to have poor inhaler technique and limited understanding of ICS function, as well as limited numeracy and print literacy. Clinicians should consider these elements of self-management for their effect on asthma care and as a marker of more general health literacy deficits.

Access to, and experiences of, healthcare services by trafficked people: findings from a mixed-methods study in England

BACKGROUND

Physical and psychological morbidity is high in trafficked people but little is known about their experiences of accessing and using healthcare services while, or after, being trafficked.

AIM

To explore trafficked people's access to, and use of, health care during and after trafficking.

DESIGN AND SETTING

A mixed-methods study - a cross-sectional survey comprising a structured interview schedule and open-ended questions - was undertaken in trafficked people's accommodation or support service offices across England.

METHOD

Participants were asked open-ended questions regarding their use of healthcare services during and after trafficking. Interviews were conducted with professionally qualified interpreters where required. Thematic analysis was used to analyse the data.

RESULTS

In total, 136 trafficked people (from 160 contacted) participated in the open-ended interviews of whom 91 (67%) were female and 45 (33%) male. Participants reported being trafficked for domestic servitude (n = 40; 29%), sexual exploitation (n = 41; 30%), and labour exploitation (for example, agriculture or factory work) (n = 52; 38%). Many responders reported that traffickers restricted access to services, accompanied them, or interpreted for them during consultations. Requirements to present identity documents to register for care, along with poor access to interpreters, were barriers to care during and after trafficking. Advocacy and assistance from support workers were critical to health service access for people who have been trafficked.

CONCLUSION

Trafficked people access health services during and after the time they are exploited, but encounter significant barriers. GPs and other practitioners would benefit from guidance on how these people can be supported to access care, especially if they lack official documentation.

Understanding negative feedback from South Asian patients: an experimental vignette study

OBJECTIVES

In many countries, minority ethnic groups report poorer care in patient surveys. This could be because they get worse care or because they respond differently to such surveys. We conducted an experiment to determine whether South Asian people in England rate simulated GP consultations the same or differently from White British people. If these groups rate consultations similarly when viewing identical simulated consultations, it would be more likely that the lower scores reported by minority ethnic groups in real surveys reflect real differences in quality of care.

DESIGN

Experimental vignette study. Trained fieldworkers completed computer-assisted personal interviews during which participants rated 3 video recordings of simulated GP-patient consultations, using 5 communication items from the English GP Patient Survey. Consultations were shown in a random order, selected from a pool of 16.

SETTING

Geographically confined areas of ∼130 households (output areas) in England, selected using proportional systematic sampling.

PARTICIPANTS

564 White British and 564 Pakistani adults recruited using an in-home face-to-face approach.

MAIN OUTCOME MEASURE

Mean differences in communication score (on a scale of 0-100) between White British and Pakistani participants, estimated from linear regression.

RESULTS

Pakistani participants, on average, scored consultations 9.8 points higher than White British participants (95% CI 8.0 to 11.7, p<0.001) when viewing the same consultations. When adjusted for age, gender, deprivation, self-rated health and video, the difference increased to 11.0 points (95% CI 8.5 to 13.6, p<0.001). The largest differences were seen when participants were older (>55) and where communication was scripted to be poor.

CONCLUSIONS

Substantial differences in ratings were found between groups, with Pakistani respondents giving higher scores than White British respondents to videos showing the same care. Our findings suggest that the lower scores reported by Pakistani patients in national surveys represent genuinely worse experiences of communication compared to the White British majority.