Preventive behaviors and knowledge of tick-borne illnesses: results of a survey from an endemic area.

CONTEXT: Lyme disease (LD) is the most commonly reported vector-borne illness in the United States. With physically and economically burdensome effects, it is a concern of public health officials. OBJECTIVES: To assess knowledge and preventive behaviors of individuals in the endemic area of Martha's Vineyard, Massachusetts, to better understand how sociodemographic data and knowledge correlate with preventive behaviors, and to update previous island studies. DESIGN: A 30-item paper-based anonymous survey in either English or Portuguese based on language preference. SETTING: The island of Martha's Vineyard and the ferry between island and mainland. PARTICIPANTS: A total of 946 participants were recruited at 1 of 4 island locations. The majority of participants were traveling by ferry to and from Martha's Vineyard. To reach 2 populations potentially at high risk, that is, youths and outdoor workers, 3 additional venues included the island high school, an English-as-a-Second-Language class, and a local Brazilian church. OUTCOME MEASURES: Four specific preventive behaviors as well as an overall composite prevention score. RESULTS: Participants' knowledge of tick-borne illnesses was poor, and the frequency of practicing preventive behaviors was low; the most commonly reported behavior was checking one's skin for ticks (45%). Approximately one-third of respondents (37%) stated that they did not know the late symptoms of untreated LD, nor did they know early LD treatment options (49%). The 2 high-risk groups reported little participation in preventive measures. In multivariate analyses, only 4 characteristics-older age, confidence in telling deer tick from wood tick, seeing tick-borne illness as a serious threat, and certainty in ability to identify LD symptoms-attained significance associated with preventive behavior as an overall composite score. CONCLUSIONS: Public health interventions focusing on accurately communicating risk, improving knowledge both of LD symptoms and of ticks that carry the disease, as well as teaching preventive behaviors may help reduce tick-borne illness rates.

Primary prevention for resettled refugees from Burma: where to begin?

Developing effective primary prevention initiatives may help recently arrived refugees retain some of their own healthy cultural habits and reduce the tendency to adopt detrimental ones. This research explores recent arrivals' knowledge regarding eating behaviors, physical activity and sleep habits. Working collaboratively with community members, a healthy living curriculum was adapted and pilot tested in focus groups. A community-engaged approach to revising and implementing a health promotion tool was effective in beginning dialogue about primary prevention among a group of recently arrived refugees from Burma. Seven themes were identified as particularly relevant: food choices, living environment, health information, financial stress, mobility/transportation, social interaction and recreation, and hopes and dreams. Refugees desire more specific information about nutrition and exercise, and they find community health workers an effective medium for delivering this information. The outcomes of this study may inform future targeted interventions for health promotion with refugees from Burma.

Public and Population Health in U.S. Medical Education: A Review of Guidance in Extraordinary Times.

ABSTRACT: Generations of medical educators have recommended including public and population health (PPH) content in the training of U.S. physicians. The COVID-19 pandemic, structural racism, epidemic gun violence, and the existential threats caused by climate change are currently unsubtle reminders of the essential nature of PPH in medical education and practice. To assess the state of PPH content in medical education, the authors reviewed relevant guidance, including policies, standards, and recommendations from national bodies that represent and oversee medical education for physicians with MD degrees.Findings confirm that guidance across the medical education continuum, from premedical education to continuing professional development, increasingly includes PPH elements that vary in specificity and breadth. Graduate medical education policies present the most comprehensive approach in both primary care and subspecialty fields. Behavioral, quantitative, social, and systems sciences are represented, although not uniformly, in guidance for every phase of training. Quantitative PPH skills are frequently presented in the context of research, but not in relation to the development of population health perspectives (e.g., evidence-based medicine, quality improvement, policy development). The interdependence between governmental public health and medical practice, environmental health, and the impact of structural racism and other systems of oppression on health are urgent concerns, yet are not consistently or explicitly included in curricular guidance. To prepare physicians to meet the health needs of patients and communities, educators should identify and address gaps and inconsistencies in PPH curricula and related guidance.Re-examinations of public health and health care systems in the wake of the COVID-19 pandemic support the importance of PPH in physician training and practice, as physicians can help to bridge clinical and public health systems. This review provides an inventory of existing guidance (presented in the appendices) to assist educators in establishing PPH as an essential foundation of physician training and practice.

Improving population health through integration of primary care and public health: providing access to physical activity for community health center patients.

OBJECTIVES: Our community health center attempted to meet public health goals for encouraging exercise in adult patients vulnerable to obesity, diabetes, hypertension, and other chronic diseases by partnering with a local YMCA. METHODS: During routine office visits, providers referred individual patients to the YMCA at no cost to the patient. After 2 years, the YMCA instituted a $10 per month patient copay for new and previously engaged health center patients. RESULTS: The copay policy change led to discontinuation of participation at the YMCA by 80% of patients. Patients who persisted at the YMCA increased their visits by 50%; however, more men than women became frequent users after institution of the copay. New users after the copay were also more likely to be younger men. Thus the copay skewed the population toward a younger group of men who exercised more frequently. Instituting a fee appeared to discourage more tentative users, specifically women and older patients who may be less physically active. CONCLUSIONS: Free access to exercise facilities (rather than self-paid memberships) may be a more appropriate approach for clinicians to begin engaging inexperienced or uncertain patients in regular fitness activities to improve health.

A new approach to ensuring oral health care for people living with HIV/AIDS: the dental case manager.

INTRODUCTION: The American Dental Association has identified several barriers to adequate dental care for vulnerable populations, including appropriate case management. The objective of this study was to examine the perceptions, attitudes, and beliefs of dental patients living with HIV/AIDS on the role and value of the dental case manager (DCM) and the effect of DCM services on their oral or overall health. METHODS: We used a qualitative descriptive study design and focus groups. Twenty-five people who had received DCM services on Cape Cod, Massachusetts, attended 1 of 5 focus groups in 2009 and 2010. Digital recordings of the groups were transcribed verbatim. Textual data were categorized using directed qualitative content analysis techniques. We identified major themes and representative quotes. RESULTS: The following themes emerged from discussions on the DCM's role: being available, knowledgeable about clients and insurance, and empathetic; increasing access; and providing comfort. Most participants credited their oral and overall health improvements to the DCM. All participants believed that the DCM was a valuable addition to the clinic and noted that other at-risk populations, including the elderly and developmentally disabled, likely would benefit from working with a DCM. CONCLUSION: The addition of a DCM facilitated access to dental care among this sample of people living with HIV/AIDS, providing them with an advocate and resulting in self-reported improvements to oral and overall health.

Partnering for health: collaborative leadership between a community health center and the YWCA central Massachusetts.

BACKGROUND: A collaborative partnership among community-based organizations (CBOs)-a community-health center, a YWCA, and 2 academic health centers-developed and implemented open access to physical activity for health center patients. OBJECTIVE: To describe partnership approach taken by 2 CBOs; determine staffs' views of this unique partnership, highlight aspects of the partnership that contributed to its success, identify challenges and mechanisms for overcoming them, and note lessons learned. Assess health center patients' use of YWCA facility. METHODS: Usage data were obtained from YWCA records. Staff were interviewed using primarily open-ended questions. Inductive approach was used to analyze qualitative data. RESULTS: The approach to partnership was largely organic, without formal working documents; nevertheless, the partnership reflected the organizations' missions. Over 4 years, 1134 health center patients made more than 23 000 visits to the YWCA. Responses of health center staff and provider interviewees about partnership processes sorted into the following categories: partnership description and results, partnership benefits, challenges, lessons learned, and advice to other CBOs. YWCA staff interviewee responses reflected the categories: staffing, clientele, and public face. Comments also included challenges, lessons learned, and advice to other YWCAs. CONCLUSIONS: This partnership achieved notable successes largely because (a) it formed to serve a specific purpose that met both agencies' goals, (b) leaders made sustained commitments, and (c) it managed conflict. The partnership has taken on new projects over time; new ideas for improving access and service to underserved patients continue to emerge. Interorganizational trust and allegiance have been key to addressing challenges; nevertheless, the organic nature of the partnership's origins and the challenges of success have meant that the partnership has restructured its agreement and, to avoid being overwhelmed, limited new patient use.

A qualitative study of the meaning of fatherhood among young urban fathers.

OBJECTIVE: To explore the beliefs, attitudes, and needs young men have regarding their role as a father. DESIGN AND SAMPLE: Exploratory, descriptive, qualitative design. Young fathers/young expectant fathers were recruited from service sites within a city in Massachusetts. Men were considered young fathers/young expectant fathers if they were or would be <20 years old at the birth of a first child or the mother of their baby was or would be <20 years old at the baby's birth and the young man was <25 years old. MEASURES: Participants were interviewed utilizing open-ended questions, which included the following: the characteristics of good fathers, goals/needs for self and child, and whether or not they planned to raise the child as their father raised them and why. RESULTS: Responses regarding fathering clustered into the following themes: being available; providing support; and self-improvement, including completing education and becoming a positive role model. Forty-seven percent believed that being employed or finishing school would help them be better fathers; 77% reported they would not raise their child as their own father had raised them, citing physical and/or emotional abuse/abandonment. CONCLUSIONS: Young men in this study identified several challenges to being "good" fathers. These included lack of employment, education, and positive role models.

Teaching Public and Population Health in Medical Education: An Evaluation Framework.

Curriculum models and training activities in medical education have been markedly enhanced to prepare physicians to address the health needs of diverse populations and to advance health equity. While different teaching and experiential learning activities in the public health and population health sciences have been implemented, there is no existing framework to measure the effectiveness of public and population health (PPH) education in medical education programs. In 2015, the Association of American Medical Colleges established the Expert Panel on Public and Population Health in Medical Education, which convened 20 U.S. medical faculty members whose goal was to develop an evaluation framework adapted from the New World Kirkpatrick Model. Institutional leaders can use this framework to assess the effectiveness of PPH curricula for learners, faculty, and community partners. It may also assist institutions with identifying opportunities to improve the integration of PPH content into medical education programs. In this article, the authors present outcomes metrics and practical curricular or institutional illustrations at each Kirkpatrick training evaluation level to assist institutions with the measurement of (1) reaction to the PPH education content, (2) learning accomplished, (3) application of knowledge and skills to practice, and (4) outcomes achieved as a result of PPH education and practice. A fifth level was added to measure the benefit of PPH curricula on the health system and population health. The framework may assist with developing a locally relevant evaluation to further integrate and support PPH education at U.S. medical schools and teaching hospitals.

Community dimensions and HPSA practice location: 30 years of family medicine training.

BACKGROUND AND OBJECTIVES: Our objective was to assess practicing family physicians' confidence and participation in a range of community-related activities. Additionally, we assessed the strength of the relationship between the physicians' reported medical school and residency training in community-related activities and their current community activities, as well as whether they were practicing in an underserved location. METHODS: All 347 graduates of the University of Massachusetts Family Medicine Residency were surveyed about practice location and type, involvement and training in community work, confidence in community-related skills, and sociodemographic characteristics. Analyses were conducted by residency graduation decade (1976-1985, 1986-1995, and 1996-2005). RESULTS: Earlier graduates (19761985) were significantly more likely to engage in an array of community-related activities, but recent graduates (1996-2005) were more likely to report having been trained in these skills. There was a significant positive association between practice in an underserved area and confidence in issues related to sociocultural aspects of care. While recent graduates were more likely to locate both initial and current practices in a Health Professions Shortage Area (HPSA), 20.6% of all graduates reported an initial practice in a HPSA. CONCLUSIONS: While family physician involvement in community-related activities increases with years out of residency, a higher proportion of recent graduates report having learned community-related skills while in medical school. Physician relocation tends to be away from HPSA toward non-HPSA sites.

Family medicine residency characteristics associated with practice in a health professions shortage area.

BACKGROUND AND OBJECTIVES: While some family medicine residency programs are designed to train residents in community health centers (CHCs) for future careers serving underserved populations, there are few outcome studies on such programs. Our residency program provides three options for ambulatory health center training, but otherwise residents participate in the same curriculum. We analyzed relationships between ambulatory training site and likelihood of practice in health professions shortage areas (HPSAs). METHODS: We sent a mail survey to all graduates of one family medicine residency about practice locations, types, and populations; influences on practice choice; and sociodemographic characteristics. RESULTS: Training in a CHC had a statistically significant association with the likelihood of practice in an HPSA for both initial and current practice. Training in a rural residency site was associated with initial and current rural practice. Logistic regression analysis showed that physicians who completed ambulatory training in the CHC were nearly six times more likely to report having practiced initially and four times more likely to cite current practice in an HPSA. CONCLUSIONS: Outpatient CHC residency training increases the likelihood of practice in an underserved setting. This finding has policy implications for supporting workforce training in practice settings that care for underserved populations.

Pre-clinical medical student reflections on implicit bias: Implications for learning and teaching.

CONTEXT: Implicit bias affects health professionals' clinical decision-making; nevertheless, published reports of medical education curricula exploring this concept have been limited. This research documents a recent approach to teaching implicit bias. METHODS: Medical students matriculating during 2014 and 2015 participated in a determinants of health course including instruction about implicit bias. Each submitted a reflective essay discussing implicit bias, the experience of taking the Implicit Association Test (IAT), and other course content. Using grounded theory methodology, student essays that discussed reactions to the IAT were analyzed for content themes based on specific statements mapping to each theme. Twenty-five percent of essays underwent a second review to calculate agreement between raters regarding identification of statements mapping to themes. OUTCOME: Of 250 essays, three-quarters discussed students' results on the IAT. Theme comments related to: a) experience taking the IAT, b) bias in medicine, and c) prescriptive comments. Most of the comments (84%) related to students' acknowledging the importance of recognizing implicit bias. More than one-half (60%) noted that bias affects clinical decision-making, and one-fifth (19%) stated that they believe it is the physician's responsibility to advocate for dismantling bias. CONCLUSIONS: Through taking the IAT and developing an understanding of implicit bias, medical students can gain insight into the effect it may have on clinical decision-making. Having pre-clinical medical students explore implicit bias through the IAT can lay a foundation for discussing this very human tendency.

Service-learning: an integral part of undergraduate public health.

In 2003, the Institute of Medicine (IOM) described public health as "an essential part of the training of citizens," a body of knowledge needed to achieve a public health literate citizenry. To achieve that end, the IOM recommended that "all undergraduates should have access to education in public health." Service-learning, a type of experiential learning, is an effective and appropriate vehicle for teaching public health and developing public health literacy. While relatively new to public health, service-learning has its historical roots in undergraduate education and has been shown to enhance students' understanding of course relevance, change student and faculty attitudes, encourage support for community initiatives, and increase student and faculty volunteerism. Grounded in collaborative relationships, service-learning grows from authentic partnerships between communities and educational institutions. Through emphasizing reciprocal learning and reflective practice, service-learning helps students develop skills needed to be effective in working with communities and ultimately achieve social change. With public health's enduring focus on social justice, introducing undergraduate students to public health through the vehicle of service-learning as part of introductory public health core courses or public health electives will help ensure that our young people are able to contribute to developing healthy communities, thus achieving the IOM's vision.

The power and the promise: working with communities to analyze data, interpret findings, and get to outcomes.

Although the intent of community-based participatory research (CBPR) is to include community voices in all phases of a research initiative, community partners appear less frequently engaged in data analysis and interpretation than in other research phases. Using 4 brief case studies, each with a different data collection methodology, we provide examples of how community members participated in data analysis, interpretation, or both, thereby strengthening community capacity and providing unique insight. The roles and skills of the community and academic partners were different from but complementary to each other. We suggest that including community partners in data analysis and interpretation, while lengthening project time, enriches insights and findings and consequently should be a focus of the next generation of CBPR initiatives.

Creating open access to exercise for low-income patients through a community collaboration for quality improvement: if you build it, they will come.

Community health centers face the need for safe, accessible, and affordable exercise for low-income patients to implement self-management strategies. This study reports on one federally qualified health center's experience developing a partnership with a local YWCA to offer open access to patients for physical activity. Over a 24-month period, 1060 adult patients made at least 1 visit to the YWCA, logging a total of 14,276 visits. Among the exercisers, 112 had diabetes and made 3225 visits. Frequent users (> or =24 visits), had an HbAlc reduction of 1% (P = .02). Community health centers can collaborate with local exercise facilities to ensure that patients have opportunities to pursue healthier lifestyles.

Adolescent mothers' attitudes toward contraceptive use before and after pregnancy.

STUDY OBJECTIVE: To understand attitudes and beliefs influencing use and nonuse of contraceptive methods pre- and postpartum among a group of adolescent mothers. DESIGN AND SETTING: Qualitative descriptive study utilizing focus groups conducted between May, 2005 and January, 2006 in Central Massachusetts. PARTICIPANTS: Adolescent mothers attending a federally funded multi-professional medical program. Inclusion criteria included being at least one year postpartum. Forty-six mothers were eligible; 34 were successfully contacted via telephone. Twenty-two agreed to attend; 15 adolescent mothers attended one of four groups. MAIN OUTCOME MEASURE: Emergent themes were identified concerning adolescent mothers' attitudes and beliefs regarding contraception pre and postpartum. RESULTS: Themes pertaining to nonuse of contraception prior to first pregnancy were: denial, not planning to have sex, not considering the consequences of unprotected sex, and wanting to become pregnant. Participants identified barriers to obtaining and utilizing contraception, including embarrassment discussing the topic, confidentiality, inability to obtain contraception without parental knowledge, and lack of knowledge regarding methods. Participants reported that convenience, perceived effectiveness, familiarity, and side effects were the primary reasons for selecting or changing a method of contraception postpartum and recommended several methods of promoting contraceptive use among adolescents. These included persuading health care providers to discuss the issue routinely with every adolescent patient, parental involvement, outreach by young mothers to at-risk teens, and media campaigns. CONCLUSIONS: Given the adverse consequences of adolescent pregnancy, understanding the attitudes and beliefs of postpartum adolescents regarding contraceptives is important for developing effective interventions. Focus groups conducted with adolescent mothers, a difficult population to engage, provide a venue for exploring this complex issue.

The visiting specialist model of rural health care delivery: a survey in Massachusetts.

CONTEXT: Hospitals in rural communities may seek to increase specialty care access by establishing clinics staffed by visiting specialists. PURPOSE: To examine the visiting specialist care delivery model in Massachusetts, including reasons specialists develop secondary rural practices and distances they travel, as well as their degree of satisfaction and intention to continue the visiting arrangement. METHODS: Visiting specialists at 11 rural hospitals were asked to complete a mailed survey. FINDINGS: Visiting specialists were almost evenly split between the medical (54%) and surgical (46%) specialties, with ophthalmology, nephrology, and obstetrics/gynecology the most common specialties reported. A higher proportion of visiting specialists than specialists statewide were male (P = .001). Supplementing their patient base and income were the most important reasons visiting specialists reported for having initiated an ancillary clinic. There was a significant negative correlation between a hospital's number of staffed beds and the total number of visiting specialists it hosted (r =-0.573, P = .032); study hospitals ranged in bed size from 15 to 129. CONCLUSIONS: The goal of matching supply of health care services with demand has been elusive. Visiting specialist clinics may represent an element of a market structure that expands access to needed services in rural areas. They should be included in any enumeration of physician availability.

Health status of a low-income vulnerable population in a community health center.

Healthcare safety net providers are under increasing pressure to meet the physical and mental health--as well as the range of social service-needs of traditionally vulnerable and hard-to-reach populations. The extent to which health center patients are less well and in poorer health than is the rest of society, thus requiring greater depth and breadth of service, has not generally been the focus of systematic assessment. This case study uses the 12-Item Short-Form Health Survey (SF-12) and selected years of healthy life questions from the National Health Interview Survey to assess the self-perceived health status of patients at one Section 330 community health center in central Massachusetts. Five hundred thirteen patients completed all questions on the SF-12; 619 completed each of the years of healthy life questions. Respondents' physical and mental component summary scores were significantly lower than national norms for all age groups (P < .001). Respondents were also significantly more likely than the civilian noninstitutionalized population to be unable to perform major activities (P < .0001) and to be in fair or poor health (P < .0001). Analyses give an indication of the magnitude of difference in self-perceived health status between this poor, vulnerable population and the citizenry at large and suggest implications for policy related to safety net healthcare facilities.

Clinical prevention and population health: curriculum framework for health professions.

The Clinical Prevention and Population Health Curriculum Framework is the initial product of the Healthy People Curriculum Task Force convened by the Association of Teachers of Preventive Medicine and the Association of Academic Health Centers. The Task Force includes representatives of allopathic and osteopathic medicine, nursing and nurse practitioners, dentistry, pharmacy, and physician assistants. The Task Force aims to accomplish the Healthy People 2010 goal of increasing the prevention content of clinical health professional education. The Curriculum Framework provides a structure for organizing curriculum, monitoring curriculum, and communicating within and among professions. The Framework contains four components: evidence base for practice, clinical preventive services-health promotion, health systems and health policy, and community aspects of practice. The full Framework includes 19 domains. The title "Clinical Prevention and Population Health" has been carefully chosen to include both individual- and population-oriented prevention efforts. It is recommended that all participating clinical health professions use this title when referring to this area of curriculum. The Task Force recommends that each profession systematically determine whether appropriate items in the Curriculum Framework are included in its standardized examinations for licensure and certification and for program accreditation.