Parent-Child Vaccination Concordance and Its Relationship to Child Age, Parent Age and Education, and Perceived Social Norms.

Researchers established that parental vaccination status often predicts that of their children, but a limited number of studies have examined factors influencing dyadic concordance or discordance (i.e., same or different vaccination status or intent for both members). We investigated how child versus parent age as well as parents' perceptions of their respective friends' immunization behavior impacted un/vaccinated parents' decisions regarding vaccinating their child. An online survey obtained the COVID-19 vaccination status and views of 762 parents of 5-17-year-old children. More than three-quarters of all dyads were concordant; 24.1% of vaccinated parents would not vaccinate their child, with greater hesitancy for younger children and among younger or less educated parents. Children of vaccinated parents and of parents who thought most of their child's friends were vaccinated were 4.7 and 1.9 times, respectively, more likely to be vaccinated; unvaccinated parents were 3.2 times more likely to accept the vaccine for their child if they believed most of their friends would vaccinate their children. Further, parents who reported that most of their friends were vaccinated were 1.9 times more likely to have obtained the vaccine themselves, illustrating the influence of social norms. Regardless of their own vaccination status, parents of unvaccinated children were more likely to be politically conservative. If communities or circles of friends could achieve or convey a vaccinated norm, this might persuade undecided or reluctant parents to vaccinate their children. Future research should examine the effects of community behavior and messages highlighting social norms on pediatric vaccine uptake.

Attitudes towards diversity, equity, and inclusion across the CTSA Programs: Strong but not uniform support and commitment.

Background: This study describes attitudes towards diversity, equity, and inclusion (DEI) among members of the Clinical and Translational Science Awards (CTSA) Program. It also explores associations between program members' roles and their perceived importance of and commitment to improving DEI and assesses the link between perceived importance of and commitment to improving DEI. Lastly, it ascertains barriers and priorities concerning health equity research, workforce development, CTSA consortium leadership, and clinical trials participation among respondents. Methods: A survey was administered to registrants of the virtual CTSA Program 2020 Fall Meeting. Respondents reported their roles, perceived importance of and commitment to improving DEI. Bivariate cross-tabulations and structural equation modeling examined associations between respondents' roles, perceived importance of DEI, and commitment to improving DEI. Grounded theory was used to code and analyze open-ended questions. Results: Among 796 registrants, 231 individuals completed the survey. DEI was "extremely important" among 72.7 percent of respondents and lowest among UL1 PIs (66.7%). Being "extremely committed" to improving DEI was reported by 56.3 percent of respondents and lowest among "other staff" (49.6%). Perceived importance of DEI was positively associated with commitment to improve DEI. Institutional and CTSA Commitment, Support, and Prioritization of DEI represented a key theme for improving DEI among respondents. Conclusion: Clinical and translational science organizations must take bold steps to transform individual perceptions of DEI into commitment and commitment into action. Institutions must set visionary objectives spanning leadership, training, research, and clinical trials research to meet the promise and benefits of a diverse NIH-supported workforce.

Academic Medicine's Fourth Mission: Building on Community-Oriented Primary Care to Achieve Community-Engaged Health Care.

A 2021 article, "Now is our time to act: Why academic medicine must embrace community collaboration as its fourth mission," by Association of American Medical Colleges (AAMC) authors, including AAMC president and CEO Dr. David J. Skorton, offers 2 aims that are highly related: community collaboration and health equity. The AAMC's call to prioritize community collaboration and health equity as pillars of the academic medicine mission echo earlier work on community-oriented primary care (COPC) and an even more robust model that builds on COPC, community-engaged health care (CEHC). COPC is a tested, systematic approach to health care by which a health clinic or system collaborates with a community to reshape priorities and services based on assessed health needs and determinants of health. COPC affirms health inequities' socioeconomic and political roots, emphasizing health care as a relationship, not a transaction or commodity. Communities where COPC is implemented often see reductions in health inequities, especially those related to socioeconomic, structural, and environmental factors. COPC was the foundation on which community health centers were built, and early models had demonstrable effects on community health and engagement. Several academic health centers build on COPC to achieve CEHC. In CEHC, primary care remains critical, but more of the academic health center's functions are pulled into community engagement and trust building. Thus, the AAMC has described and embraced a care and training model for which there are good, longitudinal examples among medical schools and teaching hospitals. Spreading CEHC and aligning the Community Health Needs Assessment requirements of academic health centers with the fourth mission could go a long way to improving equity, building trust, and repairing the social contract for health care.

Partnerships to Care for Our Patients and Communities During COVID-19.

The Coronavirus disease 2019 (COVID-19) pandemic forced not only rapid changes in how clinical care and educational programs are delivered but also challenged academic medical centers (AMCs) like never before. The pandemic made clear the need to have coordinated action based on shared data and shared resources to meet the needs of patients, learners, and communities. Family medicine departments across the country have been key partners in AMCs' responses. The Duke Department of Family Medicine and Community Health (FMCH) was involved in many aspects of Duke University's and Health System's responses, including leadership contributions in delivering employee health and student health services. The pandemic also surfaced the biological and social interactions that reveal underlying socioeconomic inequalities, for which family medicine has advocated since its inception. Key to success was the department's ability to integrate "horizontally" with the broader community, thereby accelerating the institution's response to the pandemic.

It should not require a pandemic to make community engagement in research leadership essential, not optional.

Efforts to move community engagement in research from marginalized to mainstream include the NIH requiring community engagement programs in all Clinical and Translational Science Awards (CTSAs). However, the COVID-19 pandemic has exposed how little these efforts have changed the dominant culture of clinical research. When faced with the urgent need to generate knowledge about prevention and treatment of the novel coronavirus, researchers largely neglected to involve community stakeholders early in the research process. This failure cannot be divorced from the broader context of systemic racism in the US that has contributed to Black, Indigenous, and People of Color (BIPOC) communities bearing a disproportionate toll from COVID-19, being underrepresented in COVID-19 clinical trials, and expressing greater hesitancy about COVID-19 vaccination. We call on research funders and research institutions to take decisive action to make community engagement obligatory, not optional, in all clinical and translational research and to center BIPOC communities in this process. Recommended actions include funding agencies requiring all research proposals involving human participants to include a community engagement plan, providing adequate funding to support ongoing community engagement, including community stakeholders in agency governance and proposal reviews, promoting racial and ethnic diversity in the research workforce, and making a course in community engaged research a requirement for Masters of Clinical Research curricula.

Engagement science: The core of dissemination, implementation, and translational research science.

Stakeholder engagement is acknowledged as central to dissemination and implementation (D&I) of research that generates and answers new clinical and health service research questions. There is both benefit and risk in conducting stakeholder engagement. Done wrong, it can damage trust and adversely impact study results, outcomes, and reputations. Done correctly with sensitivity, inclusion, and respect, it can significantly facilitate improvements in research prioritization, communication, design, recruitment strategies, and ultimately provide results useful to improve population and individual health. There is a recognized science of stakeholder engagement, but a general lack of knowledge that matches its strategies and approaches to particular populations of interest based on history and characteristics. This article reviews stakeholder engagement, provides several examples of its application across the range of translational research, and recommends that Clinical Translational Science Awards, with their unique geographical, systems, and historical characteristics, actively participate in deepening our understanding of stakeholder engagement science and methods within implementation and dissemination research. These recommendations include (a) development of an inventory of successful stakeholder engagement strategies; (b) coordination and intentionally testing a variety of stakeholder engagement strategies; (c) tool kit development; and (d) identification of fundamental motivators and logic models for stakeholder engagement to help align stakeholders and researchers.

A Framework for Resident Participation in Population Health.

Population health experiences have become more common in medical education. Yet, most resident population health experiences are in patient panel management and fail to connect with the rapidly growing movement of cross-sector, data-driven, and community-led initiatives dedicated to improving the health of populations defined by geography rather than insurer or employer. In this Perspective, the authors present a five-stage framework for residents' participation in the work of these initiatives. The five stages of this framework are (1) organize and prepare, (2) plan and prioritize, (3) implement, (4) monitor and evaluate, and (5) sustain. In applying this approach, residents stand to acquire new population health skills and augment the value and meaning of their work, while institutions stand to improve the health of the communities they serve, including the health of their own employees. However, a paucity of experienced role models and demanding residency schedules present significant challenges to residents effectively partnering with the community. Residencies and institutions will have to be flexible and committed to being a part of these cross-sector, data-driven, and community-led partnerships over the long term.

Developing physicians as catalysts for change.

Failures in care coordination are a reflection of larger systemic shortcomings in communication and in physician engagement in shared team leadership. Traditional medical care and medical education neither focus on nor inspire responses to the challenges of coordinating care across episodes and sites. The authors suggest that the absence of attention to gaps in the continuum of care has led physicians to attempt to function as the glue that holds the health care system together. Further, medical students and residents have little opportunity to provide feedback on care processes and rarely receive the training and support they need to assess and suggest possible improvements.The authors argue that this absence of opportunity has driven cynicism, apathy, and burnout among physicians. They support a shift in culture and medical education such that students and residents are trained and inspired to act as catalysts who initiate and expedite positive changes. To become catalyst physicians, trainees require tools to partner with patients, staff, and faculty; training in implementing change; and the perception of this work as inherent to the role of the physician.The authors recommend that medical schools consider interprofessional training to be a necessary component of medical education and that future physicians be encouraged to grow in areas outside the "purely clinical" realm. They conclude that both physician catalysts and teamwork are essential for improving care coordination, reducing apathy and burnout, and supporting optimal patient outcomes.

Teaching population health: a competency map approach to education.

A 2012 Institute of Medicine report is the latest in the growing number of calls to incorporate a population health approach in health professionals' training. Over the last decade, Duke University, particularly its Department of Community and Family Medicine, has been heavily involved with community partners in Durham, North Carolina, to improve the local community's health. On the basis of these initiatives, a group of interprofessional faculty began tackling the need to fill the curriculum gap to train future health professionals in public health practice, community engagement, critical thinking, and team skills to improve population health effectively in Durham and elsewhere. The Department of Community and Family Medicine has spent years in care delivery redesign and curriculum experimentation, design, and evaluation to distinguish the skills trainees and faculty need for population health improvement and to integrate them into educational programs. These clinical and educational experiences have led to a set of competencies that form an organizational framework for curricular planning and training. This framework delineates which learning objectives are appropriate and necessary for each learning level, from novice through expert, across multiple disciplines and domains. The resulting competency map has guided Duke's efforts to develop, implement, and assess training in population health for learners and faculty. In this article, the authors describe the competency map development process as well as examples of its application and evaluation at Duke and limitations to its use with the hope that other institutions will apply it in different settings.

Are we there yet? Seizing the moment to integrate medicine and public health.

Multiple promising but unsustainable attempts have been made to maintain programs integrating primary care and public health since the middle of the last century. During the 1960s, social justice movements expanded access to primary care and began to integrate primary care with public health concepts both to meet community needs for medical care and to begin to address the social determinants of health. Two decades later, the managed care movement offered opportunities for integration of primary care and public health as many employers and government payers attempted to control health costs and bring disease prevention strategies in line with payment mechanisms. Today, we again have the opportunity to align primary care with public health to improve the community's health.

Family physicians as team leaders: "time" to share the care.

A major contributor to shortfalls in delivery of recommended health care services is lack of physician time. On the basis of recommendations from national clinical care guidelines for preventive services and chronic disease management, and including the time needed for acute concerns, sufficiently addressing the needs of a standard patient panel of 2,500 would require 21.7 hours per day. The problem of insufficient time indicates that primary care requires broad, fundamental changes. The creation of primary care teams that include members such as physician assistants, nurse practitioners, dietitians, health educators, and lay coaches is important to meeting patients' primary care needs.

Estimated time spent on preventive services by primary care physicians.

BACKGROUND: Delivery of preventive health services in primary care is lacking. One of the main barriers is lack of time. We estimated the amount of time primary care physicians spend on important preventive health services. METHODS: We analyzed a large dataset of primary care (family and internal medicine) visits using the National Ambulatory Medical Care Survey (2001-4); analyses were conducted 2007-8. Multiple linear regression was used to estimate the amount of time spent delivering each preventive service, controlling for demographic covariates. RESULTS: Preventive visits were longer than chronic care visits (M = 22.4, SD = 11.8, M = 18.9, SD = 9.2, respectively). New patients required more time from physicians. Services on which physicians spent relatively more time were prostate specific antigen (PSA), cholesterol, Papanicolaou (Pap) smear, mammography, exercise counseling, and blood pressure. Physicians spent less time than recommended on two "A" rated ("good evidence") services, tobacco cessation and Pap smear (in preventive visits), and one "B" rated ("at least fair evidence") service, nutrition counseling. Physicians spent substantial time on two services that have an "I" rating ("inconclusive evidence of effectiveness"), PSA and exercise counseling. CONCLUSION: Even with limited time, physicians address many of the "A" rated services adequately. However, they may be spending less time than recommended for important services, especially smoking cessation, Pap smear, and nutrition counseling. Future research is needed to understand how physicians decide how to allocate their time to address preventive health.

Improving the health of the community: Duke's experience with community engagement.

Evidence is accumulating that the United States is falling behind in its potential to translate biomedical advances into practical applications for the population. Societal forces, increased awareness of health disparities, and the direction of clinical and translational research are producing a compelling case for AHCs to bridge the gaps between scientific knowledge and medical advancement and between medical advancement and health. The Duke University Health System, the city and county of Durham, North Carolina, and multiple local nonprofit and civic organizations are actively engaged in addressing this need. More than a decade ago, Duke and its community partners began collaborating on projects to meet specific, locally defined community health needs. In 2005, Duke and Durham jointly developed a set of Principles of Community Engagement reflecting the key elements of the partnership and crafted an educational infrastructure to train health professionals in the principles and practice of community engagement. And, most recently, Duke has worked to establish the Duke Translational Medicine Institute, funded in part by a National Institutes of Health Clinical Translational Science Award, to improve health through innovative behavioral, social, and medical knowledge, matched with community engagement and the information sciences.