Sociodemographic Factors, Attitudes, and Tobacco use among Adolescent Areca-Nut Users in Mumbai, India.

Introduction: Areca nut, initiated in adolescence, is considered a gateway for tobacco use and an important cause of oral cancers in India. This study examined differences in sociodemographic factors, attitudes and beliefs, and tobacco use between current (last 30 days) areca nut users and past users, who have ever used areca but not in the last 30 days. Material and Methods: A cross-sectional survey with school students attending grades 7, 8, 9 provided data to compare differences in age, gender, beliefs, attitudes, and concurrent tobacco use among self-reported areca users. Of 1909 participants surveyed, 641 (33.57%) reported use of areca nut; of which 355 (55.38%) current users had consumed it in the last 30 days. Results: A logistic regression model revealed that male gender, using tobacco concurrently, inability to refuse a friend's request to use, and intention to use areca nuts in the next 12 months were significant predictors of current areca use. Conclusion: More research is needed to understand adolescent areca-nut use, including different types of users such as experimenters and those with established habits. This will help design targeted areca-nut prevention and cessation programs.

Using the Theory of Planned Behavior to Explain and Predict Areca Nut Use Among Adolescents in India: An Exploratory Study.

Context: Areca nut, used alone or in combination with tobacco, contributes to the high oral cancer burden in India. Used widely by adolescents, who perceive it as a harmless substance, areca nut is addictive and considered a precursor to tobacco use. Given its serious implications for addictiveness and physical health, urgent preventive interventions for areca nut use are required in India and South-East Asia. Studies examining the role of health behavior theory in explaining and predicting areca nut use and for development of its prevention among adolescents are scarce. Aim: This study explored the role of the components of Theory of Planned Behavior (TPB) such as attitudes, subjective norms, perceived behavioral control, and intention in predicting areca nut use among adolescents. Settings and Design: Observational study with cross-sectional design conducted with 1884 male and female adolescents attending low-income schools in Mumbai, India. Methods and Material: Self-administered surveys were used to gather data on age, gender, behavioral factors and areca nut use. Statistical Analysis Used: Chi-square and Mann Whitney test for bivariate and logistic regression for multivariate analysis. Results: Around 27.2% of 1884 participants were areca nut users. The mean age of users was 13.75 years. Intention-to-use and perceived behavioral control were statistically significant predictors of actual areca nut use (p<0.001). The components of TPB such as attitude, perceived subjective social norms, and perceived behavioral control had a statistically significant effect on the intention-to-use areca nut (p<0.05). Conclusion: This exploratory study indicates that constructs from TPB could help us understand and predict areca nut use. However, more rigorous future research is required to generate insights that help craft effective theory-based behavioral interventions for areca nut prevention and cessation in adolescents.

Adolescents and E-cigarettes in India: A Qualitative Study of Perceptions and Practices.

PURPOSE: Global Youth Tobacco Survey-4, India conducted in 2019 showed 'ever use' of e-cigarettes among adolescents to be 2.8%. However, there is dearth of qualitative data on adolescent use of e-cigarettes in the country. This study was conducted to explore and gain better understanding on adolescents' perceptions and practices about e-cigarette use. METHODS: In-depth interviews were conducted with 24 adolescents who self-reported use of e-cigarettes. The participants were recruited from ten municipal schools of Mumbai, India that cater to students from lower socio-economic background. Participants were from 7th to 9th grades, and aged 11-16 years. Data from in-depth interviews were analyzed using inductive thematic analysis. RESULTS: Adolescents referred to 'e-cigarette' as 'pen-hookah.'  E-cigarettes were perceived as relatively harmless compared to regular hookahs and conventional cigarettes. Initiation was influenced by a friend, peer, or sibling. A variety of flavors, the after-taste, the ability to perform playful tricks with smoke, and fun-time spent with friends were cited as reasons for continued use. Social media influenced both initiation and continuation. Most adolescents' regular use was with a group of friends; the device was shared with or obtained from friends or siblings. Adolescents were unclear about the presence of nicotine in refill liquids and the harmful health effects. CONCLUSION: Increasing awareness among adolescents about the harms of e-cigarettes is urgently required through comprehensive tobacco-prevention programs. More research is needed to examine the role of flavors in increasing acceptability of e-cigarettes and how it affects perceived harmfulness of tobacco products.

Assessing the Efficacy of a Tobacco Prevention and Control Intervention in a Rural Area of India: A Quasi-Experimental Study.

Background: Tobacco use, disproportionately higher in rural areas, is a major cause of morbidity and mortality in India. Interventions to reduce tobacco use in rural areas are scarce. Objectives: The objective of this study was to assess the efficacy of a community-directed tobacco prevention intervention in reducing tobacco use in rural areas. Materials and Methods: A single-group pre-/postquasi-experimental study was conducted in Lakhmapur village, Maharashtra. Data were collected from one adult each in 296 and 307 randomly selected village households before and at the end of intervention, respectively. Results: Between pretest and posttest, reported tobacco use reduced from 56.4% to 23.5%; average daily expenditure on tobacco from INR 16.07 to INR 9.47, respectively. A logistic model, controlling for sociodemographic variables, showed that the postintervention group had a significantly lower likelihood of using tobacco; however, males and lower education subgroups were more likely to use. Conclusions: Multipronged community-based interventions involving schools, students, teachers, frontline workers, elected leaders, and community influencers hold promise in reducing tobacco use in rural India.

How Do Adolescents Assess and Rank the Risk of Areca Nut Use? Findings from a Study in Mumbai, India.

OBJECTIVE: Areca nut use, along with tobacco, is a contributor to India's high rates of oral cancer. Areca nut use is culturally accepted, often initiated early in adolescence, and said to lead to later tobacco use. Unlike tobacco prevention, there are scarce prevention or harm-reduction programmes or campaigns specifically targeted at areca nut. METHODS: A participative ranking method was used to understand adolescents' assessment of risks of areca nut. Five focus group discussions were conducted with 31 adolescents, 19 fe-male and 12 male, non-users and users of chewing tobacco, water-pipe (hookah) and areca nut. Participants categorized and ranked the risk of 16 activities, including the use of areca nut and various tobacco-products, and discussed reasons for these risk-rankings. RESULTS: Despite differences between groups on the assessment of risks associated with the 16 different activities, all the groups, user and non-user, rated cigarette smoking as having the highest risk, chewing fennel and using mouth fresheners as no risk, and areca nut as low risk. The other activities were ranked differently by each group. Adolescents' perceptions of smoking or online games as risky was influenced by greater exposure to messaging on harmful consequences of the activity through multiple channels such as mass media, interpersonal networks including parents, and classroom health-education sessions. Inadequate knowledge about the harmful consequences of areca nut use, greater social and cultural acceptability, and the sweet taste of commercially packaged areca nut influenced low-risk perceptions. CONCLUSION: Perceptions of risk from an activity often determines preventive behaviors. Presently, adolescents do not perceive areca use as risky. In comparison to smoking they con-sider it less harmful. More research is required to better understand areca nut use and its cul-tural determinants. However, targeted health communication messages and prevention poli-cies and programmes have to be initiated to reduce areca nut use and associated burden of oral cancer.

A Qualitative Study of Perceptions and Practices Related to Areca Nut Use Among Adolescents in Mumbai, India.

INTRODUCTION: Areca nut, commonly known as supari, is widely used in India. In addition to tobacco and alcohol, it has been identified as one of the contributory factors for high rates of oral cancer in the country. METHODS: This qualitative study explored perceptions and practices around the use of areca nut by conducting in-depth interviews and focus group discussions with 61 school-going adolescents in the city of Mumbai, India. RESULTS: Respondents used low-priced sachets of sweetened, flavored areca nut called supari. They perceived supari as harmless because it was sweet, it had a fresh after-taste as compared to bitter-tasting smokeless tobacco products. How can something sweet be harmful was a common argument offered by respondents. Respondents invariably compared and contrasted areca nut to more harmful and addictive tobacco products; perceiving supari to have milder or inconsequential health effects. Supari use was initiated with friends, a sibling, or a cousin. It was almost always used with friends. Respondents also reported difficulty in refusal to use when offered supari by friends. Parental response to finding out about the child's supari use was often muted in comparison to extreme reactions associated with the child's tobacco use. CONCLUSIONS: Perceptions of low risk or relative harmlessness of the product, social influence, and the features of the product itself influence adolescents' use of areca nut. Although more research on perceptions of risk, with larger samples, is required, these findings are useful for school-based tobacco prevention and cessation programs and health policy-makers. IMPLICATIONS: The study findings have implications for prevention and cessation programs, and policymakers. School-based health education programs should allocate special sessions on areca nut use. Focused mass media communication campaigns describing its harms and association with oral cancer are required for the larger community. As was done for tobacco, Indian policymakers will have to evaluate the marketing, commerce, and distribution of areca nut and create appropriate laws. More research, with larger nationwide samples, is required to examine perceptions of areca nut.

Does adding a psychosocial cessation intervention to an existing life-skills and tobacco-prevention program influence the use of tobacco and supari among secondary school students?: Findings from a quasi-experimental trial in Mumbai, India.

INTRODUCTION: This study aimed to test whether school-going adolescents who self-report tobacco and/or supari use are more likely to quit if a school-based psychosocial cessation intervention is added to an existing life-skills and tobacco-prevention program. METHODS: A quasi-experimental trial with pre-test and post-test 20 weeks after the intervention was conducted with students from low-income families in 12 schools in Mumbai; six schools were randomly assigned to the intervention and the remaining to the comparison condition. Participants were students from grades 7, 8 and 9 who self-reported tobacco and/or supari use. Intervention schools received six sessions of LifeFirst, a psychosocial group-based tobacco cessation intervention program, in addition to SuperArmy, a school-wide life-skills and tobacco-prevention program. Trained counselors facilitated the cessation intervention, which spanned five months. All students in comparison schools received only SuperArmy. The outcome measures were self-reported use of tobacco-only, supari-only, and tobacco plus supari in the past 30 days. RESULTS: The number of all users decreased by 19.1% in the intervention and 18.7% in the comparison schools at post-test. Although this reduction was significant (p<0.001) within each group, the difference between intervention and comparison schools was not significant. Further segregation by type of product used showed that for tobacco-only users there was a non-significant increase of 1.7% in intervention schools, and a significant 26.2% increase (p<0.001) in the comparison group. Tobacco plus supari use declined in both groups; however, supari-only use fell by 14.8% in the intervention and 32.7% in the comparison schools (p<0.01). CONCLUSIONS: The combination of a cessation intervention along with the life-skills and tobacco-prevention program appear to have halted tobacco-only use in the intervention group. Future research needs to determine whether students are substituting supari for tobacco and to understand the psychological mechanisms underlying the cessation intervention and the interaction between cessation and prevention-only interventions.

Adherence to the Tobacco-Free School Policy in Rural India

Background: In India, 267 million adults use tobacco with prevalence of 35% in rural areas and 13% among those between 15 and 24 years. With 40% of India's population below 19 years, tobacco-free schools (TFS) can be a critical strategy for preventing tobacco-use among youth. This study examined the extent of and factors associated with complete adherence to national TFS guidelines among rural schools in the state of Maharashtra. Methods: Trained observers visited 507 rural schools to check adherence to eleven TFS criteria and conducted a cross-sectional survey of school-level indicators. These data were coupled with school-based information from the District Information System for Education (DISE) to analyze factors associated with TFS-adherence. Results: Only 11% of schools adhered to all eleven TFS criteria. Majority (72%) prohibited sale of tobacco inside and within 100 yards of the school; 63% displayed no-smoking posters; and 59% banned tobacco use inside premises. However, only 18% consulted with state tobacco advisor and only 28% of schools had tobacco prevention messages on school stationery. Bivariate analysis revealed that complete TFS-adherence was associated with participation of school in sports (p<0.001) and extra-curricular competitions (p<0.001); internet connectivity (p<0.005) and e-learning facilities (p<0.05); and teachers' attendance at capacity-building workshops (p<0.05). A logistic model identified competitive sports participation (OR=3.27, p<0.005) as a key predictor of adherence to the TFS policy. Conclusion: This is the first study in India that measures and examines compliance among rural schools with national TFS guidelines; thus filling an existing gap in the tobacco control literature. Schools that provide students and staff with opportunities for overall development seem more likely to implement tobacco-free guidelines. By understanding the hard-to-meet criteria, policy-makers and practitioners can support schools in becoming tobacco-free. Integrating tobacco control programs with overall development goals of the school is one way forward.

The Tobacco-Free Village Program: Helping Rural Areas Implement and Achieve Goals of Tobacco Control Policies in India.

India has 274 million tobacco users and a tobacco use prevalence of 38% in rural areas. Tobacco consumption causes 1 million deaths and costs the health system nearly US$23 billion annually. Tobacco control policies exist but lack proper implementation. In this article, we review the Tobacco-free Village (TfV) program conducted in Maharashtra state in India and describe its process to help villages in rural India achieve "tobacco-free" status (i.e., the sale and use of tobacco are prohibited by law). We reviewed program documents and conducted 22 qualitative interviews with program staff and village-level stakeholders. From 2008 to 2014, Salaam Mumbai Foundation implemented the TfV program in 60 villages in Maharashtra state. The program used a number of strategies to help villages become tobacco free, including collaborating with a community-based organization, leveraging existing health workers, conducting a situation analysis, training health workers, engaging stakeholders, developing TfV assessment criteria, mobilizing the community, conducting health education, imposing sanctions, and offering incentives. By 2014, 4 villages had achieved tobacco-free status according to 11 assessment criteria. Successful villages demonstrated strong local leader involvement, ownership of the program, and commitment to the cause by residents. The TfV program faced barriers including poor motivation of health workers, difficulty in changing social norms of tobacco use, and refusal of local vendors to stop tobacco sales due to financial losses. This low-cost, community-driven program holds promise for helping public health practitioners and governments implement and achieve the goals of tobacco control policies, especially in resource-scarce settings.

Factors Associated with Tobacco Use in Students Attending Local Government Schools in Mumbai, India

Purpose: Factors associated with ever-use and differences between ever-users and non-users of tobacco among adolescent school students from low income families in Mumbai were assessed. Materials and Methods: A self-administered questionnaire, completed by 1918 students from grades 7, 8 and 9 in 12 schools managed by the city municipal corporation in July 2015, gathered data on socio-demographic characteristics, tobacco use and tobacco-related knowledge, attitudes and beliefs. Results: Although only 1% of respondents thought tobacco was cool, nearly 35% were unaware of associations between tobacco use and health problems. Male students were almost twice as likely (OR=2.5, P <= 0.05) to have ever used tobacco compared to females and Supari (areca nut) users were eight times more likely (OR=8.99, P < 0.001) than Supari non -users. Tobacco-users were more likely to agree with statements: 'People who use tobacco have more friends' (OR=2.8, P = 0.004), 'Smoking relieves stress' (OR=5.6, P = 0.002) and 'It is possible to purchase any tobacco product within 100 yards of school' (OR=10.8, P < 0.001). Conclusion: This study highlights the gains made by tobacco prevention campaigns in that almost all students did not consider tobacco as cool or a stress reliever. However, they still need education about health consequences of tobacco-use. In addition, Supari use has to be addressed in school-based tobacco prevention and cessation initiatives. Furthermore, programs must also address perceptions and norms related to peers and tobacco use and ensure active implementation of existing laws. Such integrated measures will help ensure tobacco-free spaces around schools.

'This is normal during pregnancy': a qualitative study of anaemia-related perceptions and practices among pregnant women in Mumbai, India.

OBJECTIVES: to explore anaemia-related perceptions and practices among pregnant women in Mumbai, India. DESIGN: descriptive qualitative study using in-depth interviews and focus group discussions. SETTING: three government-run maternity hospitals in Mumbai, India. PARTICIPANTS: 31 pregnant women aged 18-33 years; three women completed higher secondary school; 28 were homemakers. FINDINGS: respondents described anaemia as 'lack of blood in the body' because that was the term used by health providers; yet they did not seem worried about the consequence on their own health. Women perceived anaemia as 'normal during pregnancy' because their body had to simply share resources with the fetus and every female relative had suffered from it during pregnancy. Respondents did recognise weakness and dizziness as symptoms of anaemia. They attributed the cause to a poor diet, but did not know the specific link with iron-deficiency. They listed various negative effects of anaemia on the fetus, but very few stated ill-effects on the mother, and none stated maternal death as an outcome. Women saw their role primarily as child-bearers and prioritised newborn's health over their own. CONCLUSION AND IMPLICATIONS: anaemia stands at the intersection of health, nutrition, culture and gender. Interventions in the country have to go beyond distributing or monitoring compliance with iron-folic acid (IFA) supplements. Health education programmes for women and household members have to highlight the seriousness of anaemia and address socio-cultural norms and gendered behaviours in families with respect to nutrition and health. There is an urgent need in maternal and child health programmes to emphasise the importance of the mother's own health. Anaemia interventions have the potential to become proxies for women's health and empowerment programmes.

Provider imposed restrictions to clients' access to family planning in urban Uttar Pradesh, India: a mixed methods study.

BACKGROUND: Medical barriers refer to unnecessary policies or procedures imposed by health care providers that are not necessarily medically advised; these restrictions impede clients' access to family planning (FP). This mixed methods study investigates provider imposed barriers to provision of FP using recent quantitative and qualitative data from urban Uttar Pradesh, India. METHODS: Baseline quantitative data were collected in six cities in Uttar Pradesh, India from service delivery points (SDP), using facility audits, exit interviews, and provider surveys; for this study, the focus is on the provider surveys. More than 250 providers were surveyed in each city. Providers were asked about the FP methods they provide, and if they restrict clients' access to each method based on age, parity, partner consent, or marital status. For the qualitative research, we conducted one-on-one interviews with 21 service providers in four of the six cities in Uttar Pradesh. Each interview lasted approximately 45 minutes. RESULTS: The quantitative findings show that providers restrict clients' access to spacing and long-acting and permanent methods of FP based on age, parity, partner consent and marital status. Qualitative findings reinforce that providers, at times, make judgments about their clients' education, FP needs and ability to understand FP options thereby imposing unnecessary barriers to FP methods. CONCLUSIONS: Provider restrictions on FP methods are common in these urban Uttar Pradesh sites. This means that women who are young, unmarried, have few or no children, do not have the support of their partner, or are less educated may not be able to access or use FP or their preferred method. These findings highlight the need for in-service training for staff, with a focus on reviewing current guidelines and eligibility criteria for provision of methods.

Prevalence, pattern and determinants of mental disorders in rural Bangladesh.

OBJECTIVES: Very few studies have examined mental health morbidity in Bangladesh. This community-based study of rural Bangladesh in 2000-2001 estimated the burden of mental morbidity among rural people of working age. STUDY DESIGN AND METHODS: Community surveys were conducted with one respondent from each household of three selected villages in the service provision area of a non-profit public health organization. General Health Questionnaire 60 (GHQ-60) was used as a screening tool in Stage I, and clinical examination by a Western-trained psychiatrist was undertaken for concurrent validation in Stage II. RESULTS: The overall prevalence of psychiatric disorders in this rural area was 16.5%. Depressive disorders and anxiety disorders constituted about one-half and one-third of the total cases, respectively. A significantly higher prevalence of mental disorders was found in the economically poor respondents, those over 45 years of age, and women from large families. CONCLUSION: There is a high prevalence of psychiatric disorders in rural Bangladesh. These findings should aid the planning of locally relevant and appropriate mental healthcare programmes. There is an urgent need for a national mental healthcare policy that strengthens primary mental healthcare services.

Perceptions of risk and behaviour change for prevention of HIV among married women in Mumbai, India.

Heterosexual transmission accounts for the majority of cases in India, an epicentre of the HIV/AIDS pandemic, with increasing rates of infection in married women contracting HIV from an infected spouse. Cultural roles and position of married women in Indian society render targeted risk-reduction programmes difficult. To investigate HIV/AIDS-related knowledge, perceptions, and behaviour change among married women in India, an interview-based survey was conducted with 350 married women in Mumbai, of whom 67% (236) were aware of HIV/AIDS. Although 59.3% (140) of those aware mentioned indiscriminate sexual activity as increasing risk of HIV, only two (41%) in five women perceived HIV as a threat to the community; one (12%) in eight perceived personal risk of getting infected as high; and only 7.2% (17) reported behaviour change to avoid infection. When probed for reasons for not changing behaviour, most women cited their personal behaviour of monogamy, not being in an at-risk group, such as commercial sex workers, and trust in their husbands. Education programmes among married women that enable better understanding of risks are urgently required. Since marriage and motherhood are important in the Indian cultural context, male spouses should be included in risk-reduction programmes.

Factors associated with low birthweight in rural Bangladesh.

This study examines factors associated with low birthweight (LBW) in rural Bangladesh. Enrolled in early first trimester, 350 women were followed for duration of pregnancy and data gathered on maternal factors such as social, demographic, anthropometric, biochemical measures and newborn's birth weight within 48 hours of birth. Almost a quarter of babies (24%) were born with LBW and mean birth weight was 2961 g. Bivariate analysis found associations between LBW and mother's age, parity, weight and hemoglobin level at booking, weight gain and health problems during pregnancy, tobacco consumption, and gestational age. But no such association was seen for birth spacing, mother's height, economic status, educational level, body mass index, mid upper arm circumference and number of ANC visits. Multivariable analysis revealed gestational age, hemoglobin levels at first visit and weight gain during pregnancy as significant predictors of LBW in this rural setting. Although antenatal care provision is absolutely necessary, intervention approaches that go beyond clinical or primary care settings are also warranted for better nutrition of women. Concerted efforts in health and non-health sectors are necessary for improvement in health and social status of women in order to reduce low birthweight in Bangladesh.

Un estudio, basado en la comunidad, de las condiciones de salud ocupacional en seis actividades industriales / A community-based survey of occupational health conditions in six industrial activities

Objetivos del estudio: Este estudio basado en la comunidad, examinó las condiciones de salud ocupacional y seguridad en seis industrias mexicanas y comparó los resultados obtenidos con informes de salud ocupacional del gobierno. Diseño: Entrevistas personales estructuradas para recopilar información acerca de las condiciones de trabajo, lesiones y enfermedades de los trabajadores de 32 fábricas centinelas en cuatro ciudades industriales en México. De estas fábricas se tomó una muestra dirigida de 3.651 trabajadores actualmente empleados. Principales resultados: Los daños a la salud reportados con mayor frecuencia fueron lesiones ocupacionales y enfermedades pulmonares. La frecuencia de lesiones graves y mortales y de casi todas las otras enfermedades, fueron mayores en las industrias más grandes del cemento, automotriz y vidrio. Los trabajadores en las industrias de tamaño medio y pequeño de alimentos, calzado y textil reportaron menor frecuencia de equipo de seguridad y capacitación en seguridad. Conclusiones: La prevalencia de lesiones y enfermedades entre los trabajadores e industrias estudiadas fue más alta que aquellos datos reportados por organismos oficiales. Una opción factible en términos de recursos invertidos y calidad de la información reunida es la implementación de estudios periódicos de prevalencia de enfermedades ocupacionales y lesiones en la comunidad. Este tipo de estudio permite evaluar la eficacia de las políticas y programas oficiales de salud para el mejoramiento de las condiciones de salud y seguridad ocupacional, y para detectar cambios en la salud asociados con los impactos en la economía global.

Perspectives on obesity and barriers to control from workers at a community center serving low-income Hispanic children and families.

Community center workers serving children and families in a predominantly Hispanic, low-income neighborhood were interviewed qualitatively, to ascertain their perspectives on obesity and barriers to control and prevention, to design a practical and culturally appropriate intervention for obesity control. All 19 respondents recognized obesity as a problem, identified healthy eating and physical activity as requisites for controlling obesity, and mentioned fast food and cultural influences in Hispanic families as contributory factors. Lack of time emerged as a major barrier to all preventive practices related to eating healthy or being physically active. Safety concerns and lack of safe places for walking and running were mentioned as a barrier to being physically active. Further studies have to be conducted with parents of at-risk children, to understand time constraints. Community health workers should be sensitive to issues of time constraints and incorporate time management recommendations into obesity prevention and education.

Infusing the Interdisciplinary into Medical/ Health Sciences Education: Vitamins or Vaccines?

Academic medical institutions have responded to recent changes and challenges confronting the health care system with various recommendations for curricular reform; many grouped under the rubric of interdisciplinary training. The ultimate goal is to create physicians, with mastery over specialized knowledge, who can practice cost-effective, humanized medicine. This article elaborates a conceptual classification system that categorizes curricular reform recommendations into one of two approaches ? Vitamins or Vaccines ? that highlights differences in the processes of curricular reform programs. Programs seeking the same goal may create different types of practitioners depending on the approach dominating the professional training and socialization process. The Vitamins approach is reactive, supplemental, and incremental, often imparting instruction instead of education. The Vaccines approach is proactive, addresses fundamental factors, and seeks long-term solutions from a preventive perspective. As educators, our choice of approach, Vitamins or Vaccines, for curricular reform will determine how academia prepares physicians for the future.