A classroom-based physical activity intervention for urban kindergarten and first-grade students: a feasibility study.

BACKGROUND: Urban elementary schools in minority communities with high obesity prevalence may have limited resources for physical education (PE) to achieve daily activity recommendations. Little is known whether integrating physical activity (PA) into classrooms can increase activity levels of students attending such schools. METHODS: We conducted a cluster randomized, controlled trial among kindergarten and first-grade students from four Bronx, New York, schools to determine feasibility and impact of a classroom-based intervention on students' PA levels. Students in two intervention schools received the Children's Hospital at Montefiore Joining Academics and Movement (CHAM JAM), an audio CD consisting of 10-minute, education-focused aerobic activities led by teachers three times a day. PA was objectively measured by pedometer. Each subject wore a sealed pedometer during the 6-hour school day for 5 consecutive days at baseline (Time 1) and 8 weeks postintervention (Time 2). Hierarchical linear models were fit to evaluate differences in mean number of steps between the two groups. RESULTS: A total of 988 students participated (intervention group, n=500; control group, n=488). There was no significant difference at baseline between the two groups on mean number of steps (2581 [standard deviation (SD), 1284] vs. 2476 [SD, 1180]; P=0.71). Eight weeks post-CHAM JAM, intervention group students took significantly greater mean number of steps than controls (2839 [SD, 1262] vs. 2545 [SD, 1153]; P=0.0048) after adjusting for baseline number of steps and other covariates (grade, gender, recess, and PE class). CHAM JAM was equally effective in gender, grade level, and BMI subgroups. CONCLUSIONS: CHAM JAM significantly increased school-based PA among kindergarten and first-grade students in inner-city schools. This approach holds promise as a cost-effective means to integrate the physical and cognitive benefits of PA into high-risk schools.

Physical activity during school in urban minority kindergarten and first-grade students.

OBJECTIVES: To determine if physical activity (PA) during the school day varied by school, grade level, gender, weight status, and physical education (PE) and recess participation among urban kindergarten and first-grade students. METHODS: Cross-sectional study at 4 Bronx, NY, schools. Student PA was measured by a Yamax Digi-Walker pedometer, an objective and validated measure of PA in children. Each student wore a sealed pedometer during school for 5 consecutive days. Hierarchical models were fit to identify variables predictive of PA. RESULTS: A total of 916 had valid pedometer data (53% male, 70% Hispanic, mean age 5.98 years [SD 0.66], 45% overweight). PA varied by school (P < .0001). First-grade students took a significantly greater mean number of steps during school than kindergarten students. Overall, students took an average of 2479.7 (SD 961.8) steps/school day. PA did not differ by BMI status. Students took on average 724 more steps on PE days than on non-PE days and 490 more steps on days with outdoor recess than nonrecess days (P < .05 for both). Fewer than 1% of all students achieved lower cut points for previously published mean range of steps/school day for boys and girls. Multivariable analysis revealed higher grade level, participation in PE class, and outdoor recess as independent predictors of PA. CONCLUSIONS: PA levels were low in kindergarten and first-grade students. Future interventions incorporating classroom-based PA and outdoor recess may increase PA in resource-poor urban schools with limited PE facilities.

Measurement of inhaled corticosteroid adherence in inner-city, minority children with persistent asthma by parental report and integrated dose counter.

Parents often overreport adherence to asthma treatment regimens making accurate assessment of medication adherence in clinical practice difficult. This study was conducted to compare two adherence assessment methods clinicians may choose from when assessing patient inhaled corticosteroid (ICS) adherence: parental report and dose counter measurements of metered-dose inhaler (MDI) actuation. Participants included children (N = 50) with persistent asthma and their parents (N = 50). At enrollment, children received a new, marked ICS at the dose prescribed by their physician. Thirty days following enrollment, we measured ICS adherence by parental report and objectively, with a dose counter. Parental report overestimated ICS adherence when compared to dose counter. We found a statistically significant overall difference between parental report and objectively measured adherence. A dose counter that most ICS inhalers are equipped with may be a more reliable alternative measure of ICS adherence in a clinical practice setting.

Student perceptions of effectiveness of the eight step preceptor (ESP) model in the ambulatory setting.

BACKGROUND: Balancing consistently effective clinical teaching with quality patient care is a crucial challenge for ambulatory preceptors. Educators have developed frameworks of specific teaching behaviors to facilitate consistent, efficient precepting, but few have evaluated their effectiveness. We modified an existing precepting model by incorporating additional adult learning principles to create the Eight Step Preceptor (ESP) model. We then determined if students perceived faculty to be more effective teachers when they incorporated more ESP components into their precepting sessions. PURPOSES: The objective was to describe the association between faculty using the ESP behaviors during their precepting and medical students' satisfaction with their learning. METHODS: A trained observer timed the duration of precepting sessions in a children's hospital ambulatory clinic between August and November 2001. Students rated faculty "teaching effectiveness," and both students and observer rated whether faculty effectively incorporated ESP behaviors during each session. RESULTS: Sessions lasted on average 26 +/- 14 min. Faculty gave a teaching point and feedback in over 50% of the precepting sessions but did not consistently incorporate the other ESP behaviors. Faculty use of more ESP behaviors correlated significantly with greater teaching effectiveness (r = .62, p < .003) but not significantly with duration of precepting sessions. CONCLUSIONS: Students perceived faculty as more effective teachers when they incorporated more ESP behaviors while precepting. The ESP model was associated with more effective ambulatory precepting in our study.

Using unannounced standardized patients to assess residents' competency in asthma severity classification.

OBJECTIVE: The aim of this study was to test the hypothesis that an educational intervention would increase the competency of pediatric residents in classifying asthma severity as assessed using unannounced standardized patients (SPs). METHODS: Six SPs were trained to represent mild-intermittent, mild-persistent, moderate-persistent, and severe-persistent asthma. Data from a control group were obtained in 2002-2003. In 2003-2004, after an intervention, data were collected from an intervention group. The intervention consisted of a didactic session and posting the criteria for asthma severity classification. During precepting, faculty obtained a commitment from residents (N = 12) regarding the severity classification. Faculty and residents were blinded to the presence of SPs. The assigned severity of each SP was used as the criterion standard. Residents' severity classification was compared with the criterion standard. To test whether competency improved postintervention, we compared residents' performance by using intervention group versus control group and within-subject control comparisons. Bivariate analyses tested differences in proportions of categorical variables. RESULTS: Fifty resident-SP encounters were analyzed. The intervention group performed significantly better than controls at each level of training in identifying persistent asthma: postgraduate year 3 (PGY3, 100% vs 71%), PGY2 (71% vs 50%), and PGY1 (50% vs 43%). They also performed significantly better in determining subclassifications of persistent asthma: PGY3 (87% vs 40%), PGY2 (67% vs 33%), and PGY1 (50% vs 33%). All had P < .05. Similarly, for within-subject control comparison, residents performed significantly better postintervention at identification and subclassification of persistent asthma than did the same residents at baseline. CONCLUSIONS: An educational intervention resulted in significant improvements in the competency of residents in asthma severity classification.

Residents' asthma communication skills in announced versus unannounced standardized patient exercises.

OBJECTIVE: The aim of this study was to test the hypothesis that pediatric residents would display similar levels of asthma interpersonal and communication skills in announced versus unannounced adolescent standardized patient (SP) encounters. METHODS: We conducted a prospective repeat measures experimental study at a pediatric residency program at an inner-city children's hospital. A cohort of residents (N = 18) was subjected at random to 3 SP exercises: announced and being directly observed by faculty, announced and not observed by faculty, and unannounced and unobserved. Six adolescent SPs were trained to complete checklists that included items like asthma daytime and nighttime symptoms, exercise-induced symptoms, triggers, and asthma education. For the unannounced exercises, SPs were inserted into residents' regularly scheduled clinics. Standardized patients rated residents immediately following each exercise. Residents were rated by faculty following the observed encounter. Faculty rating validated SP ratings on the observed encounter. Differences in proportions of categorical variables were tested by chi-square analyses. RESULTS: Fifty-four resident-SP encounters were analyzed. Residents consistently displayed significantly lower levels of desired behaviors in interpersonal and communication skills in the unannounced SP encounters on 10 of 14 checklist items. For example, residents asked about exercise-induced symptoms 90% of the time in announced/observed encounters versus 95% in announced/unobserved encounters versus 72% in unannounced/unobserved encounters (P = .001). There were no significant differences in residents' behaviors in the announced SP exercises (whether observed or unobserved). CONCLUSION: In this study, residents demonstrated lower levels of asthma communication skills during unannounced SP exercises. By using unannounced SPs, we were able to assess residents' interpersonal and communication skills in real clinical settings.

Improving medical student feedback with a clinical encounter card.

OBJECTIVE: We previously developed a Clinical Encounter Card (CEC) for use in medical student feedback. However, no prior studies have investigated the effectiveness of the CEC. The objective of our study was to determine whether use of the CEC would increase medical students' perception of the feedback they received. METHODS: We conducted a time-series repeated-measures experimental study at a pediatric clerkship site. The study included a crossover design with experimental and control arms. Third-year medical students on the ambulatory rotations were the experimental arm, and inpatient students were the control arm. Students and faculty in the experimental arm received the CEC, which listed 7 feedback domains: history and interviewing, physical examination, oral presentation, written notes, patient assessment, management plan, and professionalism. We used a 10-point Likert-type scale to record responses of students weekly regarding their perceptions of having received feedback in the 7 domains. Multivariate analysis of variance for repeat measures tested mean differences in continuous variables, and Mann-Whitney U rank order sum tested ordinal rank differences. RESULTS: We received 504 reports from students regarding the feedback they received. We found statistically significant improvements in 6 feedback domains for experimental subjects: history/interviewing, physical examination, oral presentation, written notes, patient assessment, and management plan. There was no improvement in feedback received about professionalism. CONCLUSIONS: Use of the CEC resulted in students' perceiving increased feedback as evidenced by significant improvements in several medical student feedback domains.

Oral rehydration therapy: is anyone drinking?

OBJECTIVES: To examine attitudes toward the use of oral rehydration therapy (ORT) by pediatric emergency medicine physicians before and after being given recent data that might affect their practice and to see if there is a difference in responses based upon year of graduation from medical school. METHODS: A national survey of all members of the American Academy of Pediatrics' Section on Emergency Medicine was conducted. Respondents were asked about their use of ORT for mild, moderate, and severe dehydration, and then presented with data refuting the concern for longer emergency department length of stay with ORT. Participants were then asked about their knowledge of, agreement with, and reaction to these data. Demographic information, such as board eligibility and year of graduation from medical school, was also obtained. The graduates were plotted on a distribution curve by year of graduation, and the group was split into thirds. RESULTS: The response rate was 59%. Before being presented with new data, earlier medical school graduates used ORT 86% for mild and 33% for moderate dehydration, whereas recent graduates used ORT 95% for mild dehydration and 55% for moderate dehydration. Overall, only 23% of physicians were familiar with the new data, but 80% agreed with the new data, and 83% would now incorporate ORT into their practice. Although the earliest graduates were as familiar with the new data as recent graduates (24% vs. 19%), they were less likely to agree with the new data (74% vs. 90%) and to incorporate ORT into practice (75% vs. 92%). CONCLUSIONS: When pediatric emergency medicine physicians are presented with data refuting the perceived barrier of prolonged time for the use of ORT, more practitioners reported that they would use ORT for mild to moderate dehydration. However, a substantial number, especially those who graduated medical school earliest, would maintain their current practice. Additional barriers need to be explored.

Health literacy among English-speaking parents in a poor urban setting.

We surveyed English-speaking parents attending an inner-city health center. Subjects read the label on a bottle of liquid medicine and 1) demonstrated how much medicine they should give, 2) stated how many times a day they should give the medicine, and 3) stated when they should give the next dose. We calculated adjusted odds ratios to test for the likelihood of incorrect medication dosing for subjects with and without demographic risk factors. Three hundred twenty six subjects participated. Overall, 252 (77%) demonstrated incorrect medication dosing. Medication dosing was more likely to be incorrect among young parents (AOR 2.45; CI 1.14, 5.26), immigrants (AOR 2.27; CI 1.04, 4.96), subjects without a high school degree (AOR 2.05; CI 1.04,4.05), and those who did not recall ever having been shown how to use a medicine dropper (AOR 1.79; CI 1.01,3.19). Implications for practice are discussed.

Tuberculin skin testing in children.

In 1996, the American Academy of Pediatrics (AAP) recommended targeted tuberculin skin testing (TST) of children while discouraging routine TST of children without risk factors for tuberculosis (TB). Recent studies have provided evidence in support of the targeted TST and recommendations that favor risk assessment over universal screening with TST. While evidence for targeted TB testing exists and benefits of screening programs are clear, administrative logistics could be a greater issue. The challenge for public health and school officials is to develop a screening program that avoids stigmatization of the at-risk group. Until then, pediatric healthcare providers will continue to have a key role in identifying children at risk for latent TB infection by using the AAP-endorsed risk-assessment questionnaire and should screen children with TST only when >1 risk factor is present.

Availability of Spanish prescription labels.

The research team conducted a cross-sectional telephone survey of all pharmacies in the Bronx, New York (99.4% participation rate) to determine availability of Spanish prescription labels. One hundred twenty five pharmacies (78%) were small independent pharmacies; 36 (22%) were large-chain pharmacies. Overall, 111 (69%) stated that they could provide prescription labels in Spanish. Overall, for all the pharmacy ZIP codes, the mean proportion of the population that was Spanish-speaking was 46.8% (range 11% to 71.6%). Seventy-eight (48%) pharmacies were located in areas where more than 50% of the population were Spanish-speaking, 48 (30%) were located in areas with 25.1-50% Spanish-speakers, and 35 (22%) were in areas with up to 25% Spanish-speakers. Small independent pharmacies were more likely than large chain pharmacies to provide prescription labels in Spanish (71% vs. 61%, p=0.25). All the pharmacists commented that a patient must specifically request a Spanish prescription label in order to receive one. Pharmacies located in areas with the highest proportion of Spanish speakers were more likely to provide prescription labels in Spanish (82% vs. 62% vs. 49%; p=.001). Of the 111 pharmacies that could provide Spanish labels, 95 (86%) used a computer program to perform the translation and 16(14%) used a lay employee. Of pharmacies using a computer program, only one had a Spanish-speaking pharmacist who could check and correct the computer translations.