A case study: lessons learned from online tutorial to improve practice readiness for family medicine residents in Palestine.

BACKGROUND: Geopolitical and socioeconomic challenges limit faculty development and clinical teaching in Palestine and many other developing countries. The first, and still only, Family Medicine (FM) residency program is a four-year program based out of An-Najah University in the West Bank. Training in primary care clinics occurs in the final two years and there are many challenges to adequate supervision in the clinical setting that were exacerbated during the pandemic. To improve the readiness for practice skills of 13 Palestinian FM residents a three-month tutorial program was organized in 2020. A nongovernmental organization (NGO) that has worked to support Family Medicine development in the region engaged experienced British and American General Practitioners trained as tutors to offer online tutorials. We examined the program as a case study to understand the factors that facilitated or impaired a positive virtual learning environment in a middle/low income country. METHODS: The tutors and residents were divided into groups and met virtually between June and September 2020. Evaluations and session reports collected during the program, the text of an online chat, and responses to an online survey two years later were collected. Using thematic analysis techniques, we evaluated the value for the residents at the time and two years later and identified factors that facilitated or impaired a positive virtual learning environment. RESULTS: Themes of knowledge, skills, attitudes, cultural disconnects, and tutorial logistics emerged. The group with the most stable tutor pairing, including one Arabic-speaker familiar with the context, was the most engaged. The all-female group formed a chat group to share real-time case questions during clinical practice and focused on skills (e.g. conducting a thorough medication review) and attitudes (e.g. open to sharing and discussing uncertainties). Other groups were less cohesive. CONCLUSIONS: Transnational tutorials that focused on clinical thinking and decision-making skills were most successful when the tutorial pair was stable, offered familiarity with the language and addressed cultural differences. Intrinsic factors such as lacking the motivation to participate and extrinsic factors such as unstable internet and rolling electric cuts, and clinical structures that made applying new skills challenging were more difficult to address but must be considered.

Virtual class room as a learning format in a family medicine residency program: Lessons learned in Palestine.

PURPOSE: Due to geopolitical and socioeconomic challenges, the Family Medicine (FM) speciality in Palestine is in early stages of development. Volunteer British General Practitioner (BGP) trainers worked with FM faculty to develop an online tutorial program (OTP) and a novel evaluation framework E-QUaL (Evaluation-Quality, Utilization and Learning) to enhance residents' patient-centered communication and clinical skills. MATERIALS AND METHODS: Three OTP cycles were facilitated and evaluated at An Najah National University (ANNU) in Palestine between 2017-2020. Qualitative data were collected during focus groups and online chats and analysed. RESULTS AND CONCLUSIONS: The development and joint facilitation of the OTP developed faculty skills and enhanced clinically oriented education. The collaborative (BGPs and ANNU faculty) approach and the use of the EQUaL framework helped to identify and address strengths and opportunities as well as the challenges and threats of the educational content and the virtual learning format with each iteration. The COVID pandemic provided a new and inexpensive platform which improved training quality. Issues such as the volunteer nature of BGPs, internet instability, and differing cultural approaches and expectations between physicians and patients were addressed in a continuous quality improvement approach and continues today. This may be a useful model in other low resourced settings.

Factors affecting nurses' intention to accept the COVID-19 vaccine: A cross-sectional study.

OBJECTIVE: To measure COVID-19 vaccine acceptance and related factors to undercover nurses' concerns and fears. DESIGN: A cross-sectional study. SAMPLE: The study included 639 nurses; 83% were women and 80% under 50 years. MEASUREMENT: A self-administered questionnaire was used. It included demographic characteristics, COVID-19-related fears and concerns, COVID-19 vaccine perceived benefits, and intention toward getting the vaccine. RESULTS: Forty percent of the nurses planned to get the vaccine when available, 41% would take it later when adequate protection and safety were presented, and 18% would never take it. Significant factors associated with vaccination intention were as follows: age (adjusted OR 1.42, 95% CI: 1.02-1.99); lack of knowledge about the vaccine (adjusted OR 2.6, 95% CI 1.81-3.8); concern about long-term side effects (adjusted OR 2.0, 95% CI 1.4-2.9); fear of injection (adjusted OR 1.5, 95% CI 1.04-2.13); natural immunity preference (adjusted OR 5.8, 95% CI 4.5-8.3); media misrepresentation (adjusted OR 1.7, 95% CI 1.2-2.4); and getting COVID-19 from the vaccine (adjusted OR 1.5, 95% CI 1.1-2.1). CONCLUSION: COVID-19 vaccine safety and side-effects concerns impact nurses' intentions to accept the vaccine and may result in low acceptance rates. Urgent action is needed to address these fears and raise confidence, as nurses' vaccine-related decisions can affect the public's vaccine acceptance.

Development of a global health curriculum for family medicine based on ACGME competencies.

BACKGROUND: With the popularity of global health among medical students and residents, family medicine (FM) residencies are developing pathways in global health. Curriculum based on Accreditation Council for Graduate Medical Education (ACGME) competencies adds rigor to the efforts. DESCRIPTION: We describe the adaptation of a comprehensive pediatric global health curriculum based on ACGME competencies for family medicine. The curriculum maps out goals, objectives, curricular elements, and evaluation modalities for each of the six competencies (medical knowledge, patient care, practice-based learning, professionalism, communication, and systems-based practice). A literature review, followed by an iterative process, guided the expansion of the pediatric curriculum and the prioritization of domains for FM. Input was sought from FM global health faculty at our 8 residencies, affiliated community faculty, and international health experts from across the United States who attended our workshop at a national FM global health meeting. The final product includes comprehensive competency-based curriculum, open-source resources, and evaluation modalities. The goals and objectives pertinent to all FM residents, and those specific to global health pathway residents and fellows, are outlined. EVALUATION: The limiting and enabling factors of the curriculum implementation are presented. CONCLUSIONS: This global family medicine curriculum has added structure and rigor to our international electives in the department at the University of Minnesota. The competency-based curriculum is in the early stages of implementation and evaluation. It has already strengthened components of the residency learning experience for all residents. A robust evaluation is needed and requires monitoring pathway graduates and their career choices into the future. The curriculum is available for adoption by other FM residencies.

Profiles of rural longitudinal integrated clerkship students: a descriptive study of six consecutive student cohorts *.

BACKGROUND: Medical schools worldwide are challenged to address the rural primary care workforce shortage by creating community-engaged curricula to nurture student interest in rural practice. AIM: To examine the personal characteristics of six consecutive rural longitudinal integrated clerkship student cohorts to understand whom the programs attract and select and thus inform the development of such programs. METHOD: A cross-sectional cohort design was used. Six cohorts (2007-2012) completed a survey on demographics and factors that influenced their choice of rural primary care. The Temperament and Character Inventory was used to measure personality. Analysis was mainly descriptive. Where appropriate univariate analysis compared variables between groups. RESULTS: Sample size was 205 with the majority female (61%), between 25 and 29 years (64%), single (60%) and lived longest in rural communities with populations less than 20,000 (60%). Rural lifestyle, background and desire to work in underserved areas were noted to impact rural medicine interest. Professional satisfaction, personal and professional goals and family needs had the highest impact on career decisions, and financial concerns lowest. CONCLUSION: The stability of students' personal characteristics across cohorts and the workforce outcomes of this program suggest the recruitment process successfully nurtures students who will fit well into future rural practice.

Exploring the Perceptions of Nurses on Receiving the SARS CoV-2 Vaccine in Palestine: A Qualitative Study.

BACKGROUND: Uncertainty about vaccination among nurses are major barriers to managing the ongoing COVID-19 pandemic worldwide. PURPOSE: To explore nurses perceptions about receiving the SARS CoV-2 vaccine to inform the upcoming Palestinian Ministry of Health (MOH) vaccination efforts. METHODS: Four focus groups were conducted with nurses between January 18 and 30, 2021, before MOH launched vaccinations in Palestine. Participants working in government and private facilities were invited to participate and completed an online or paper form to provide demographics, review the study purpose, and give consent. Meetings were facilitated in Arabic either online via the Zoom platform or face-to-face using the same interview guide. Transcripts were translated into English and coded using a template analysis approach. RESULTS: Forty-six nurses, with a median age of 29.5y (range, 22-57) from across Palestine participated. Three major themes emerged: uncertainty, trust, and the knowledge needed to move forward. Uncertainty related to the evolving nature of COVID-19, the rapidity of vaccine development, the types and timing of available vaccines. The need for trusted experts to share scientific information about the vaccines to counteract the misinformation in social media. Moreover, reliable vaccine information may help vaccine-hesitant nurses move to vaccine-acceptors and to convince others, including their patients. CONCLUSION: The negative perception of nurses towards vaccines is problematic in Palestine and uncertainty about which vaccine(s) will be available adds to the lack of education and mass-media misinformation. Other countries with vaccination efforts that are not wholly planned or implemented and may be struggling with similar concerns.

Comparison of methods for identifying ano-genital injury after consensual intercourse.

BACKGROUND: Microtrauma occurs after consensual intercourse. Understanding the injury pattern from consensual intercourse may enlighten our understanding of the ano-genital injury after sexual assault. OBJECTIVE: The purpose of this report is to compare consensual intercourse-related ano-genital injury prevalence by using three different forensic examination techniques: 1) direct visual inspection, 2) colposcopy, and 3) toluidine-blue contrast application. METHODS: Using a descriptive, comparative design, 120 female volunteers, aged 21 years or older, were examined after consensual sexual intercourse using the above techniques. Ano-genital injuries were noted using the TEARS classification (Tears, Ecchymoses, Abrasions, Redness, and Swelling). RESULTS: Direct visualization and colposcopy yielded similar ano-genital injury findings. However, more tears and abrasions of the external genitalia were identified with toluidine-blue than with direct visual inspection or colposcopy (p < 0.05). More tears were identified on the anus with toluidine-blue as compared to direct visualization (p < 0.05), but not colposcopy. Fewer ecchymoses were identified on the internal genitalia and fewer areas of redness were identified on both the external and internal genitalia when toluidine-blue was used, as compared to either direct visualization or colposcopy (p < 0.05). CONCLUSIONS: The scientific community needs to continue to build information about ano-genital injury prevalence after consensual sexual intercourse. Understanding the ano-genital injury patterns, including frequency and prevalence, that occur with consensual sexual intercourse will help to identify the difference between injury related to consensual vs. non-consensual sexual intercourse. At this time, toluidine-blue staining may add value to the sexual assault forensic examination. It is the health care provider's role to collect all possible evidence and the courts' role to determine what evidence is admissible and to ensure a rightful conviction.

Palestinian Health Care Workers' Stress and Stressors During COVID-19 Pandemic: A Cross-Sectional Study.

BACKGROUND: COVID-19 is thought to be the most significant public health threat the modern world has encountered. Health care workers (HCWs) face enormous pressure due to work overload, negative emotions, exhaustion, lack of contact with their families, and risk of catching the infection and death. AIM: This study aims to assess the level of stress perceived by HCWs and possible associated factors during the COVID-19 outbreak in Palestine. METHODS: A cross-sectional sample of 430 frontlines HCWs was conducted using an online self-reported questionnaire. HCWs' stress from the COVID-19 outbreak, factors that increase stress, and the activities that reduced stress were assessed. Chi-square test was used to compare between a categorical variable and the study outcome; associations are presented as odds ratios (OR) and confidence intervals (95% CI) with 0.05 significance level. Al-Najah National University institutional review board granted ethics approval. RESULTS: Most respondents (74.0%) reported high-stress levels during the outbreak. Fear of transmitting the virus to family was the most stressful factor (91.6%). HCWs who did not have training on the outbreak response were more likely to have high-stress levels (OR = 2.7 [95% CI = 1.7-4.4], P < .001). Those with high stress reported being disappointed (OR = 2.4 [95% CI = 1.5-3.6], P < .001), and strongly considered taking sick leave (OR = 3.9 [95% CI = 1.9-7.9], P < .001). CONCLUSION: HCWs are under tremendous stress, given the ongoing COVID-19 pandemic. Understanding the psychological impact of the outbreak on HCWs and the activities that mitigate the stress is crucial to guide policies and interventions that can maintain psychological well-being.

Mixed Method Study to Explore Ethical Dilemmas and Health Care Workers' Willingness to Work Amid COVID-19 Pandemic in Palestine.

Background: The high potential risks involved in working in a healthcare setting during a pandemic and the associated fear that may affect health care workers' (HCWs') willingness to work are important to understand to eliminate potential barriers to working. This study aimed to assess Palestinian HCWs' willingness to work and the related factors as well as to explore their ethical dilemmas during the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: Quantitative (survey questionnaire) and qualitative (semi-structured interviews) data were collected. Frontline HCWs (n = 550) received an online survey link via closed institutional networks. Frequencies summarized the data, and chi-square compared variables and outcomes. Odds ratios (ORs) and multivariable analysis examined predictors for willingness to work. Fifteen HCWs (physicians, nurses, and lab and radiology technicians) were purposefully sampled and agreed to interviews to explore their thoughts, motivations, and worries. Thematic analysis focused on ethical dilemmas to enhance the breadth and the depth of the study. Results: Almost 25% of surveyed HCWs were not willing to work during the pandemic. Logistic model results showed that physicians and nurses had higher willingness to work than others (p = 0.004, Adj. OR = 3.5). Lower stress levels and longer professional experience were predictors of more willing to work (p = 0.03, Adj. OR = 2.5; p = 0.03, Adj. OR = 2.6, respectively). Interviews showed that willingness to work did not preclude HCWs from fulfilling their duties despite grueling workloads and grave fears about safety and security. HCWs felt poorly prepared, unappreciated, and frustrated by unfair work distribution. The occupation presented additional safety issues. Conclusion: Physicians and nurses were more likely to comply with a commitment to their professional ethics and the duty or obligation to work. Stress levels could be mitigated in the future with better leadership, adding supports to address mental health and psychosocial challenges to enhance HCWs' well-being and improve quality of care. The realities of the occupation added additional threats and uncertainty.

Diabetic retinopathy screening barriers among Palestinian primary health care patients: a qualitative study.

PURPOSE: Diabetic Retinopathy (DR) screening among Palestinian diabetic patients is limited. To improve the care of our patients, we explored the barriers to DR screening with a qualitative study. METHODS: Three focus groups were conducted in the northern West Bank. Patients noncompliant with DR screening were recruited from Primary Health Care clinics. Questions were adapted from similar published studies. Informed consent was obtained and group discussions were audio recorded, transcribed, and analyzed for themes by three researchers. RESULTS: Most patients reported financial barriers including the costs of the exam and additional treatments, and transportation to the referral clinic. System related issues were the difficulty of getting appointments and long wait times due to inadequate numbers of ophthalmologists or screening facilities, and physicians failing to recommend screening. Personal concerns related to patients having other priorities, fears about the results, and the negative experiences of family members. Finally, cultural aspects included the stigma of wearing glasses and not doing a test for a condition without symptoms. CONCLUSIONS: Barriers to completing retinopathy screening are multidimensional with financial, personal, educational, health system, and cultural factors. These should be taken into consideration by policy makers in order to increase the uptake and quality of service.

Learning professionalism during the third year of medical school in a 9-month-clinical rotation in rural Minnesota.

BACKGROUND: Professionalism is now an explicit part of the medical school curricula. AIM: To examine the components that are part of developing professionalism during the Rural Physician Associate Program (RPAP) experience, a 9-month rotation in a rural community during the third year of medical school. METHODS: Two researchers analysed 3 years of essays for themes. IRB approval was obtained. RESULTS: Themes were organized using Van de Camp's model of professionalism. Students described how patients taught them about illnesses, the affects on their lives and the lives of their families. Preceptors role-modelled how to relate to patients with compassion and respect (Professionalism Towards the Patient). As a member of the health care team, clinic and hospital staff taught students how to be a good team member (Towards Other Health Care Professionals). Shadowing preceptors in their roles as physicians and community members, students learned about their responsibilities to the community (Towards the Public). Multiple opportunities for self-evaluation and reflection taught students to know themselves and find balance between work responsibilities and their personal lives (Towards Oneself). CONCLUSION: The RPAP appears to create a supportive learning environment that incorporates psychological safety, appreciation of differences, openness to new ideas and time for reflection - an ideal environment for developing professionalism.

The development of a sexual abuse severity score: characteristics of childhood sexual abuse associated with trauma symptomatology, somatization, and alcohol abuse.

Childhood sexual abuse (CSA) is common and is associated with both mental and physical health problems in adulthood. Using data from an age- and sex-stratified population survey of 600 Olmsted County, Minnesota, residents, a Sexual Abuse Severity Score was developed. The abuse characteristics of 156 CSA respondents were associated with self-reported trauma, somatization, and alcohol use. Characteristics included age of first sexual abuse, more than one perpetrator, degree of coercion, severity of abuse (i.e., attempted intercourse is more severe than fondling), and the number of occurrences. This is one of the few reports to develop a risk summary that quantifies the severity of CSA.

Pilot study to build capacity for family medicine with abbreviated, low-cost training programme with minimal impact on patient care for a cohort of 84 general practitioners caring for Palestinian refugees in Jordan.

PURPOSE: Studies document that primary care improves health outcomes and controls costs. In regions of the world where primary care is underdeveloped, building capacity is essential. Most capacity building programmes are expensive and take physicians away from their clinical settings. We describe a programme created, delivered and evaluated from 2013 to 2014 in Jordan. DESIGN: Cohort study. SETTING: Physicians providing primary care in the United Nations Relief and Works Agency for Palestine Refugees clinics in Jordan. PARTICIPANTS: Eighty-four general practitioners (GPs) were invited to participate and completed the training and evaluation. GPs are physicians who have a license to practice medicine after completing medical school and a 1 year hospital-based rotating internship. Although GPs provide care in the ambulatory setting, their hospital-based education provides little preparation for delivering ambulatory primary care. INTERVENTION/PROGRAMME: This three-stage programme included needs assessment, didactics and on-the-job coaching. First, the learning needs and baseline knowledge of the trainees were assessed and the findings guided curriculum development. During the second stage, 48 hours of didactics covered topics such as communications skills and disease management. The third stage was delivered one on one in the trainee's clinical setting for a 4 to 6-hour block. The first, middle and final patient interactions were evaluated. PRIMARY AND SECONDARY OUTCOME MEASURES: Preknowledge and postknowledge assessments were compared. The clinical checklist, developed for the programme, assessed eight domains of clinical skills such as communication and history taking on a five-point Likert scale during the patient interaction. RESULTS: Preknowledge and postknowledge assessments demonstrated significantly improved scores, 46% to 81% (p<0.0001). Trainee's clinical checklist scores improved over the assessment intervals. Satisfaction with the training was high. CONCLUSION: This programme is a potential model for building primary care capacity at low cost and with little impact on patient care that addresses both knowledge and clinical skills on the job.

Forensic sexual assault examination and genital injury: is skin color a source of health disparity?

PURPOSE: The study objectives were to (1) estimate the frequency, prevalence, type, and location of anogenital injury in black and white women after consensual sex and (2) investigate the role of skin color in the detection of injury during the forensic sexual assault examination. METHODS: A cross-sectional descriptive design was used with 120 healthy volunteers who underwent a well-controlled forensic examination after consensual sexual intercourse. RESULTS: Fifty-five percent of the sample had at least 1 anogenital injury after consensual intercourse; percentages significantly differed between white (68%) and black (43%) participants (P = .02). Race/ethnicity was a significant predictor of injury prevalence and frequency in the external genitalia but not in the internal genitalia or anus. However, skin color variables--lightness/darkness-, redness/greenness-, and yellowness/blueness-confounded the original relationship between race/ethnicity and injury occurrence and frequency in the external genitalia, and 1 skin color variable--redness/greenness--was significantly associated with injury occurrence and frequency in the internal genitalia. CONCLUSIONS: Although differences exist in anogenital injury frequency and prevalence between black and white women, such differences can be more fully explained by variations in skin color rather than race/ethnicity. Clinical recommendations and criminal justice implications are discussed.

Implementing a stroke system of care in a rural hospital: a case report from Granite Falls.

Acute stroke is a leading cause of morbidity and mortality. Both time-sensitive treatment and telemedicine are being used to improve the care of stroke patients in rural areas. This article highlights the case of a 62-year-old male patient with sudden onset of right-sided hemiparesis and a family history of vascular disease and how he was treated at a rural hospital that was connected by telemedicine technology to an urban tertiary care center. It also reviews protocols for acute treatment of stroke and systems of stroke care in rural areas.

Accuracy of five domestic violence screening questions with nongraphic language.

To assess the accuracy of 5 domestic violence screening questions designed with less graphic language that they may be appropriate when children are present, mothers (n = 400) were recruited from primary care waiting rooms. Sensitivities, specificities, and predictive values were calculated using the revised Conflict Tactic Scale. "How do you and your partner work out arguments?" was the best individual question (area under the receiver operating characteristics curve 0.82, sensitivity 25%, specificity 97.7%). The 3-question combination with the domains of argument, safety, and manner of treating you and the children had the best results (area under the receiver operating characteristics curve 0.86, sensitivity 45.5%, and specificity 94.6%). The high specificity suggests a less graphic and potentially more acceptable group of questions for introductory discussions about domestic violence.

Family violence quality assessment tool for primary care offices.

BACKGROUND: Clinicians are mandated reporters for child abuse and elder abuse. Medical organizations recommend that patients be assessed for domestic violence. To date, the only quality improvement instrument related to family violence is a tool for assessing hospitals' domestic violence efforts. METHODS: Using the Delphi method of consensus among national experts, we modified the hospital tool (Delphi Instrument for Domestic Violence for Hospital Programs) to make it applicable for primary care offices assessing for family violence (child abuse, intimate partner violence, and elder abuse). Face validity and the ability of an office/nurse manager to complete the tool independently were tested in 32 primary care practices in Ohio and Minnesota. RESULTS: The final instrument includes 111 items divided into 9 categories with a total possible score of 100%. The highest score among primary care practices was 91.4%, achieved by a family medicine office. Offices that focused on family violence-related issues for more than 4 years and were located in an urban area had higher scores. CONCLUSIONS: The US Preventive Guideline task force calls for tools related to violence screening and management. To our knowledge, this represents the first family violence quality improvement tool for primary care offices.

Abuse behavior inventory: cutpoint, validity, and characterization of discrepancies.

This study determines a clinical cutting score for the 29-item Abuse Behavior Inventory (ABI) developed by Shepard and Campbell (1992) to measure both physical and psychological abuse experiences. The authors report on a sample of 392 White and African American women from primary care waiting rooms, who completed the ABI and the revised Conflict Tactics Scale (CTS2). An ABI cutoff score of 10 maximizes validity and produces a sensitivity of 77% and a specificity of 81% compared to the CTS2. Cronbach's alpha is .92 for the entire scale, .91 for the psychological subscale, and .86 for the physical subscale. Correlation between the ABI and CTS2 is .76, with subscale correlations of .74 between ABI psychological and CTS2 verbal aggression, and .71 between ABI physical and CTS2 physical aggression, injury, and sexual coercion.

Applying the planned care model to intimate partner violence.

PURPOSE: This article presents the steps for organizing a health organization's response to intimate partner violence (IPV) according to the Planned Care Model (PCM). IPV is common and costly and results in poor physical and mental health outcomes for victims and their families. Because most care is not acute, a planned approach that crosses systems may result in more comprehensive and higher quality care. Community collaboration with IPV agencies is especially critical. The health care organization must make IPV a priority and set policies and systems to identify and manage patients, train staff, and measure, monitor, and provide feedback on outcomes. Other key PCM components include: practice design--design systems to identify and track victims, stratify risk, and coordinate care; evidence-based decision support--choose validated IPV screening questions and guidelines for identification, management, and referral and make them available in a systematic way with ongoing assessment and feedback to providers and other members of the health care team; patient self-management--self-man-agement materials should be selected and disseminated to those working with IPV victims; and data information systems--these should support a confidential patient registry and efforts to audit and provide feedback about identification and referral efforts. Process and outcome measures based on the management guidelines and protocols should be developed and monitored, and the results disseminated. CONCLUSION: Adapting PCM for the management of IPV stretches the traditional acute approach to IPV of screen-identify-refer. It expands the PCM into new realms, including embracing new partners, trying innovative ways to measure return on investment, grappling with ethical dilemmas, and designing a multifactorial evaluation across systems.