Experiential Learning as a Path to Critical Consciousness in the Medical Curriculum: A Qualitative Study.

OBJECTIVES: Clinical settings are increasingly focused on addressing patients' social needs, thus medical education must prepare future clinicians for this task. Critical consciousness, an awareness that puts health within a broader social, historical, and cultural context, could help shape students' understanding of patient social needs. Our paper explores how experiential learning through participation in a social care intervention deepened students' critical consciousness, or their understanding of the systems and structures that make it difficult for patients to meet their basic needs. METHODS: We conducted one-on-one semistructured interviews with all 24 students who served as advocates for the intervention. Of the 24 advocates, 75% (n = 18) were first-year medical students, 17% (n = 4) were public health students, and 8% (n = 2) were social work students. Interviews were audiorecorded, transcribed verbatim, and analyzed using framework analysis. RESULTS: We identified themes informed by critical consciousness, including individual (assumptions and biases), interpersonal (communication and relationship), and structural (organization and power) factors. Within these categories, advocates expressed deeper self-awareness of personal biases (individual), the importance of interpersonal communication to build trust with caregivers (interpersonal), and the identification of the structural factors that influence health, such as housing conditions (structural). The advocates highlighted the importance of experiential learning to help them understand social determinants of health. By witnessing multiple patients experiencing social needs, advocates saw the cascading effects of social needs, the structures that make it difficult to meet basic needs, and the effect on health and healthcare behavior. CONCLUSION: Students engaged in the intervention demonstrated the development of critical consciousness. Although limited, our findings suggest that when students engage with patients around social needs, students can better understand the broader social context of patients' lives. Experiential learning through social care interventions may have the potential to influence critical consciousness development and shape the practice of future clinicians.

Adolescent Health Risk Behaviors, Adverse Experiences, and Self-reported Hunger: Analysis of 10 States from the 2019 Youth Risk Behavior Surveys.

We examined associations between adolescent self-reported hunger, health risk behaviors, and adverse experiences during the 2018-2019 school year. Youth Risk Behavior Survey data were pooled from 10 states. Prevalence ratios were calculated, and we assessed effect measure modification by sex. The prevalence of self-reported hunger was 13%. Self-reported hunger was associated with a higher prevalence of every health risk behavior/adverse experience analyzed, even after adjusting for sex, grade, and race/ethnicity. Sex did not modify associations. Findings underscore needs for longitudinal research with more robust measures of adolescent food insecurity to clarify the temporality of relationships.

Racial/Ethnic Differences in the Association Between Food Security and Depressive Symptoms Among Adult Foreign-Born Immigrants in the US: A Cross-Sectional Study.

Foreign-born immigrants are at greater risks of both food insecurity and depressive symptoms, while the association between the two has yet to be elucidated. Our sample includes 6,857 adults aged 20 years and older from the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2016. Multivariable logistic regression was used to examine whether the association between food security and depressive symptoms varies across race/ethnicity among US foreign-born immigrants. The prevalence of depressive symptoms was 9.6% and 15.7% for low food security (LFS) and very low food security (VLFS). The adjust odds ratios (aORs) of depressive symptoms among Mexican American and Other Hispanic immigrants with VLFS were 2.66 (95% Confidence interval [CI]: 1.61, 4.38) and 2.05 (95% CI: 1.08, 3.86) as compared to those with full food security (FFS). Race/ethnicity may modify the association between food security and depressive symptoms among US foreign-born immigrants and a dose-response relationship was indicated among Hispanic and Other Race immigrants.

Food Insecurity and Suicidal Behaviors Among US High School Students.

BACKGROUND: Food insecurity (FI) rates in the United States are particularly high among households with children. This research set aims to analyze if high school students experiencing FI had higher risk for mental health and suicidal behaviors. METHODS: Using combined data from 11 states that conducted the 2017 Youth Risk Behavior Survey, a total of 26,962 and 24,051 high school students were used to estimate race/ethnicity and sex-stratified prevalence ratios (PRs) from Poisson regression models. A single-question was used to measure the exposure of FI and outcomes of mental health and suicidal behaviors. RESULTS: Overall, 10.8% of students reported FI. Students experiencing FI had increased risk for all mental health and suicide behavior outcomes, regardless of their race/ethnicity or sex. PRs ranged from 1.9 (95% confidence interval [CI]:1.8, 2.0) to 3.1 (CI: 2.7, 3.6). Among males, PRs for the association between FI and all outcomes were highest among non-Hispanic black students (PRs ranged from 2.4 [CI: 1.7, 3.2] to 5.5 [CI: 2.3, 13.3]). Among females, PRs were highest among non-Hispanic white students (PRs ranged from 1.9 [CI:1.7, 2.1] to 3.6 [CI:2.9, 4.5]). CONCLUSIONS: FI is consistently associated with mental health and suicidal behaviors among different subgroups of students.

Work-Family Conflict, Depression, and Burnout Among Jail Correctional Officers: A 1-Year Prospective Study.

BACKGROUND: Correctional officers (COs) experience elevated rates of mental and physical ill-health as compared with other general industry and public safety occupations. The purpose of this study was to investigate demographic, mental health, job tenure, and work-family characteristics and their prospective association to burnout within and between jail officers during one year of new employment. METHODS: In 2016, newly hired jail officers (N = 144) completed self-reported surveys across four time points in a one-year prospective study at a Midwestern United States urban jail. Linear mixed-effects and growth modeling examined how work-family conflict (W-FC) and depressive symptoms relate to perceptions of burnout over time. RESULTS: Jail officer burnout increased and was related to rises in W-FC and depression symptoms. Within-person variance for W-FC (B pooled  = .52, p < .001) and depression symptoms (B pooled  = .06, p < .01) were significant predictors of burnout. Less time on the job remained a significant predictor of burnout across all analyses (B pooled  = .03, p < .001). CONCLUSIONS: Results from this study indicate that burnout increased during the first year of new employment; and increased W-FC, higher depression, and brief tenure were associated with burnout among jail COs. Future study of correctional workplace health is needed to identify tailored, multilevel interventions that address burnout and W-FC prevention and early intervention among COs.

Total Worker Health® Needs Assessment to Identify Workplace Mental Health Interventions in Rural and Urban Jails.

IMPORTANCE: Jail officers are an underserved population of public safety workers at high risk for developing chronic mental health conditions. OBJECTIVE: In response to national calls for the examination of stressors related to the unique work contexts of correctional facilities, we implemented a pilot study informed by the Total Worker Health® (TWH) strategy at two urban and two rural jails. DESIGN: Participatory teams guided areas of interest for a mixed-data needs assessment, including surveys with 320 jail officers to inform focus groups (N = 40). SETTING: Urban and rural jails in the midwestern United States. PARTICIPANTS: Jail correctional officers and sheriff's deputies employed at participating jails. MEASURES: We measured mental health characteristics using the Patient-Reported Outcomes Measurement Information System Global Mental Health scale, the Center for Epidemiologic Studies Depression scale, and the two-item Posttraumatic Stress Disorder Checklist. Constructs to identify workplace characteristics included emotional support, work-family conflict, dangerousness, health climate, organizational operations, effectiveness of training, quality of supervision, and organizational fairness. RESULTS: On the basis of general population estimates, we found that jail officers were at higher risk for mental health disorders, including depression and posttraumatic stress disorder. Jail officers identified workplace health interventions to address individual-, interpersonal-, institutional-, and community-level needs. CONCLUSION: Implementation of a TWH needs assessment in urban and rural jails to identify evidence-informed, multilevel interventions was found to be feasible. Using this assessment, we identified specific workplace health protection and promotion solutions. WHAT THIS ARTICLE ADDS: Results from this study support the profession's vision to influence policies, environments, and systems through collaborative work. This TWH study has implications for practice and research by addressing mental health needs among jail officers and by providing practical applications to create evidence-informed, tailored interventions to promote workplace health in rural and urban jails.

Antibiotic use in goats: role of experience and education of Missouri veterinarians.

BACKGROUND: In a previous study, we found that rates of antibiotic residues in goat carcasses in Missouri were three times the published national average, warranting further research in this area. METHODS: We conducted a cross-sectional survey of goat veterinarians to determine attitudes and practices regarding antibiotics, recruiting 725 veterinarians listed on the American Association of Small Ruminant Practitioners (AASRP) website and 64 Missouri Veterinary Medical Association (MVMA) veterinarians. RESULTS: We collected 189 responses (26.1%) from AASRP members (170 valid) and 8 (12.5%) from MVMA veterinarians totalling 178 responses. While the vast majority of all veterinarians indicated that they prescribed antibiotics less than half of the time, Missouri veterinarians indicated that they spent more time treating goats for overt disease like intestinal parasites and less time on proactive practices such as reproductive herd health management comparatively. While veterinarians agreed that antibiotic resistance was a growing concern, veterinarians outside of Missouri seemed more confident that their own prescription practices was not a contributor. Although nationally most veterinarians felt that attending continuing education classes was beneficial, 73.4% in other states attended classes on antibiotic use compared to only four of the nine Missouri veterinarians. CONCLUSION: Missouri veterinarians had less veterinary experience than veterinarians in other states, and this, in conjunction with low continuing education requirements in Missouri relative to most other states, may hinder development of more proactive and effective client-veterinary relationships.

Food Insecurity Screening in Pediatric Clinical Settings: A Caregivers' Perspective.

OBJECTIVES: Food insecurity (FI) has serious academic, social, and physical health consequences for children. A recent clinical recommendation suggests FI screening during child well visits. While FI screening research has considered clinician feedback, little is known about caregivers' experience of disclosing FI to health care providers. Our paper explores caregivers' barriers and facilitators to FI disclosure. METHODS: A survey on factors influencing FI disclosure was completed in a pediatric clinic waiting room in St. Louis, MO. Among households with FI, 15 caregivers participated in a qualitative interview. Caregivers were asked about experiences discussing FI with health care providers. We calculated frequencies for survey responses and analyzed interview data using thematic content analysis. RESULTS: Caregivers highlighted stigma, fear of child being taken away, and shame as barriers to FI disclosure. Caregivers identified strong interpersonal skills, open body language, and empathy as facilitators to disclosure at the interpersonal level. Provider initiated conversations, consideration of FI disclosure in the presence of a child, and normalization of FI discussions within the clinic were described as ways to encourage FI disclosure at the organizational level. In response to FI disclosure, caregivers would like providers to offer resources including referrals to community-based resources extending beyond food. CONCLUSIONS FOR PRACTICE: Our study identifies considerations for FI screening in health care settings, spanning the social-ecological model, from the perspective of caregivers. To successfully screen and address FI, multifaceted health care interventions should address barriers and promote facilitators across multiple levels and in consideration of multiple social needs.

Antibiotic Use on Goat Farms: An Investigation of Knowledge, Attitudes, and Behaviors of Missouri Goat Farmers.

Use of low dose, prophylactic antibiotics contributes to the emergence of antibiotic resistant bacteria. In one study, goat meat in Missouri was found to have a higher percentage of antibiotic residues at slaughter than the national average, so we attempted to identify factors related to goat production that may contribute to this issue. Using the knowledge, attitude, and behavior (KAB) model, we interviewed 11 Missouri goat farmers about factors affecting antibiotic use. Most of the farmers did not have specific protocols for managing illnesses and only relied on veterinarians for major health issues. Many felt veterinarians lacked knowledge about goat medicine so instead relied on other farmers' or their own experiences for treatment modalities. While most agreed that antibiotic resistance was a concern, only 4 of the 11 indicated that they only used antibiotics when prescribed by the veterinarian. Veterinarians should be relied on and valued for their medical expertise, but they are not always being utilized in this manner. Therefore, veterinary education should emphasize goat health management to a greater extent than it currently does, and soft skills to build collaborative relationships with farmers should be taught to promote preventative health measures and more judicious use of antibiotics.

An Unexpected, Yet Welcomed Outcome of the St. Louis Healthy Start Program.

Introduction Racial disparities in birth outcomes are a significant problem in the U.S. The St. Louis Healthy Start (SLHS) program, funded for 14 years, had a goal of reducing disparate rates of poor birth outcomes in three disadvantaged communities in the St. Louis area. The Making Change Happen Leadership Academy (MCHLA) was an unanticipated community-driven effort that grew out of SLHS and continues today. The primary goal of the MCHLA is to empower women to gain mastery over their lives and use their power to improve birth outcomes in their communities. Methods Qualitative interviews were conducted with MCHLA participants to determine the impact of participation in the MCHLA on their leadership skills and attitudes. Results Participants reported positive attitudes about themselves including increased confidence and improved parenting skills. Through active participation in project work, they noted increased professional and advocacy skills and recognition of the importance of their voice. As leaders, they recognized the importance of giving and receiving emotional, tangible, and information social support. The small sample prevents us from confidently reporting that findings directly relate to the MCHLA. Discussion Leaders exist in all communities. Public health practitioners may help enhance and develop leaders with tangible support. We need to encourage more MCHLA type programs while systematically evaluating their impact on empowerment in underserved women.

Determinants of organ donation registration.

Rates of organ donor registration range from 20% to 60% throughout the United States. The purpose of this study was to examine sociogeographic differences in organ donor registration rates throughout Missouri to identify varying patterns The organ donor registration rate from each Department of Motor Vehicle office in Missouri was extracted from the National Organ Registration database, office locations were geocoded, and census tract level sociodemographic characteristics were extracted. Spatial regression analyses were conducted to identify relationships between location of DMV offices and census tract-level concentrated disadvantage. Census tract-level concentrated disadvantage (education attainment, poverty, single-headed households) had a significant negative relationship with organ donor registration rates. Yet, census tract-level African American/Black resident concentration was not significantly related to organ donor registration rates. These findings suggest that race-based interventions to recruit organ donors may no longer be necessary. Yet, identifying how characteristics of concentrated disadvantage may be more influential in determining organ donor registration. Gaining a better understanding of how individual decisions are made is integral in the context of increased life expectancy in conjunction with the complex management of chronic conditions.

Armed Conflict in Central America and Immigrant Food Insecurity in the United States.

Central American immigrants to the United States are a growing population with rates of food insecurity that exceed national averages. We analyzed multiple years of data from the Center for System Peace and the Current Population Survey, Food Security Survey Module, from 1998 to 2015. We used ordered probit and probit regressions to quantify associations between premigration residence in a country exposed to armed conflict in Central America and the food insecurity of immigrants in the United States. The study sample included 5682 females and 5801 males between the ages of 19 and 69 years who were born in Central America and migrated to the United States. The mean age of individuals included in the study sample was 38.2 years for females (standard deviation, 11.0) and 36.8 years for males (standard deviation, 10.6). Premigration armed conflict was associated with a 10.7% point increase in postmigration food insecurity among females (95% confidence interval, 6.8-14.5), and a 9.5% point increase among males (95% confidence interval, 5.0-14.0).

Implementing and Evaluating Environmental and Policy Interventions for Promoting Physical Activity in Rural Schools.

BACKGROUND: Schools are an important setting for improving behaviors associated with obesity, including physical activity. However, within schools there is often a tension between spending time on activities promoting academic achievement and those promoting physical activity. METHODS: A community-based intervention provided administrators and teachers with a training on evidence-based public health and then collaborated with them to identify and implement environmental (walking track) and local school policy interventions (brain breaks). The evaluation included conducting in-depth interviews and SOPLAY observations to assess the facilitators and barriers and impact of the dissemination of environmental and policy changes. RESULTS: Individual, organizational, intervention, and contextual factors influenced dissemination. Teachers reported that brain breaks increased student focus and engagement with classroom material and decreased student behavioral problems. Students decreased sedentary behavior and increased vigorous behavior. Of the 4 schools, 2 increased walking. CONCLUSIONS: Active dissemination of environmental and policy interventions by engaging school administrators and teachers in planning and implementation shows potential for increasing physical activity in rural school settings.

Advancing system and policy changes for social and racial justice: comparing a Rural and Urban Community-Based Participatory Research Partnership in the U.S.

BACKGROUND: The paper examines the role of community-based participatory research (CBPR) within the context of social justice literature and practice. METHODS: Two CBPR case studies addressing health inequities related to Type 2 Diabetes and Cardiovascular disease were selected from a national cross-site study assessing effective academic-community research partnerships. One CBPR partnership works with African Americans in rural Pemiscot County, Missouri and the other CBPR partnership works with African American and Latinos in urban South Bronx, New York City. Data collection included semi-structured key informant interviews and focus groups. Analysis focused on partnerships' context/history and their use of multiple justice-oriented strategies to achieve systemic and policy changes in order to address social determinants of health in their communities. RESULTS: Community context and history shaped each partnership's strategies to address social determinants. Four social justice approaches (identity/recognition, procedural, distributive, and structural justice) used by both partnerships were identified. These social justice approaches were employed to address underlying causes of inequitable distribution of resources and power structures, while remaining within a scientific research framework. CONCLUSION: CBPR can bridge the role of science with civic engagement and political participation, empowering community members to become political agents who integrate evidence into their social justice organizing strategies.

Facilitators and barriers to the adoption of ergonomic solutions in construction.

BACKGROUND: Rates of musculoskeletal disorders in construction remain high. Few studies have described barriers and facilitators to the use of available ergonomic solutions. This paper describes these barriers and facilitators and their relationship to the level of adoption. METHODS: Three analysts rated 16 proposed ergonomic solutions from a participatory ergonomics study and assessed the level of adoption, six adoption characteristics, and identified the category of adoption from a theoretical model. RESULTS: Twelve solutions were always or intermittently used and were rated positively for characteristics of relative advantage, compatibility with existing work processes and trialability. Locus of control (worker vs. contractor) was not related to adoption. Simple solutions faced fewer barriers to adoption than those rated as complex. CONCLUSIONS: Specific adoption characteristics can help predict the use of new ergonomic solutions in construction. Adoption of complex solutions must involve multiple stakeholders, more time, and shifts in culture or work systems. Am. J. Ind. Med. 60:295-305, 2017. © 2017 Wiley Periodicals, Inc.

Screening for Food Insecurity in Pediatric Clinical Settings: Opportunities and Barriers.

Food insecurity is a serious health concern among children in the United States with 15.3 million children living in food insecure households. The American Academy of Pediatrics recommends that pediatricians screen for food insecurity at health maintenance visits as identifying children at risk is a crucial step in the amelioration of food insecurity. Two surveys were administered in a Midwest pediatric clinic. A cross-sectional survey was electronically distributed to pediatric providers to assess perceptions of food insecurity among patients, provider readiness to conduct food security screenings, and barriers to conducting those screenings. A cross-sectional caregiver survey was administered to assess demographics, household food security status, participation in nutrition assistance programs, and barriers to getting enough food to eat. Descriptive statistics and odds ratios were calculated. Eighty-eight percent of physicians believe that food insecurity is a challenge for some of their patients. Only 15 % of providers reported screening for food insecurity, while 80 % were willing to screen. Physicians were most concerned with knowing how to handle a positive screen. Among caregivers, 57 % screened positive for food insecurity. Those experiencing food insecurity were more likely to be non-white, participate in SNAP and to feel discomfort towards the idea of talking to a doctor or nurse about food needs. Caregivers reporting food insecurity were significantly less likely to have a personal vehicle. Effective food insecurity screening requires addressing caregiver and health provider barriers in order to increase the likelihood of identifying households most at risk.

Adaptation of a Modified DASH Diet to a Rural African American Community Setting.

INTRODUCTION: Cardiovascular disease is the leading cause of death among African Americans in the U.S., with high blood pressure and obesity being two of the main determinants. The Dietary Approaches to Stop Hypertension diet is effective in changing behaviors associated with these health concerns, but has not been adapted to community settings. METHODS: Men on the Move: Growing Communities (MOTMGC) was evaluated using a quasi-experimental cross-sectional design. Surveys were conducted with rural African Americans aged ≥18 years prior to the intervention (2008) and at the end of the project (2013), with the final analysis conducted in 2015. Using a community-based participatory research approach, MOTMGC provided culturally appropriate education and changes to the environment to improve access to fruits and vegetables, low-fat, and low-sodium foods. RESULTS: Declines in prevalence of overweight and obese respondents and hypertension were seen in the intervention but not the comparison county. Participants with high levels of participation reported eating five or more servings of fruits and vegetables a day, a greater variety of fruits and vegetables, less salt, and seasoning their vegetables with less fat more often than those who did not participate in educational activities. Participants reported that as a result of their access to MOTMGC gardens, they were more likely to eat more fruits, vegetables, and locally grown food, and less processed food and fast food. CONCLUSIONS: Adapting the Dietary Approaches to Stop Hypertension diet to community settings through culturally appropriate community-based efforts can improve dietary behaviors, BMI, and blood pressure.