Surveillance or Engagement: Children's Conflicts During Health Maintenance Visits.

OBJECTIVE: School-aged health maintenance visits seek to prevent or intervene early with health issues of lifelong importance. Little is known about what children expect to happen in these visits or how they experience them, factors related to their engagement as active collaborators in care. METHODS: Thirty children (53% Latino, 27% African-American, and 20% white) ages 7 to 11 years were video recorded during a health maintenance visit and then interviewed while reviewing the videos. Interview transcripts were analyzed for understanding the purpose of the visit, feelings of comfort and discomfort, and decisions about how much to participate. RESULTS: Children expected doctors to be helpful, caring, and a source of important information. They anticipated visits to include immunizations, a physical examination, and praise for accomplishments, but could be surprised by questions about behavior, family function, and lifestyle. During visits, feelings varied from warmth toward providers to embarrassment, wariness, irritation, and boredom. Even when bored or irritated, children hesitated to interrupt parent-provider conversations or correct perceived provider misunderstandings, not wanting to be seen as inappropriate or rude. When asked questions they considered off topic, likely to reveal sensitive information, or that could lead to changes in their lifestyle, some were silent or answered evasively. Some said they would have spoken more freely without their parent present but valued parental support and wanted parents to make important decisions. CONCLUSIONS: School-aged children's limited knowledge of what to expect in health maintenance visits, uncertainty about conversational norms with adults, and desire to assert control over their lives compete with their desire to access expert advice and form bonds with providers. Engaging children in health maintenance visits might require more relationship-building and education about the visit's goals.

Primary Care Interventions to Prevent or Treat Traumatic Stress in Childhood: A Systematic Review.

OBJECTIVES: To systematically assess the evidence base for prevention and treatment of child traumatic stress in primary care settings. DATA SOURCES: PubMed, Embase, PsycINFO, Scopus, Academic Search Complete, CINAHL, Web of Science, Cochrane Library, the National Registry of Evidence-based Programs and Practices, the National Child Traumatic Stress Network website, Google search. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: Studies were eligible for inclusion if they described the results of intervention studies in a primary care setting addressing child traumatic stress. Study participants could include primary care providers, pediatric patients, and their parents or other caregivers. STUDY APPRAISAL AND SYNTHESIS METHODS: Each study was assessed for inclusion, and each included study was assessed for risk of bias by 2 reviewers. RESULTS: We found 12 articles describing 10 different studies that met the inclusion criteria. The intervention approaches taken in the studies were diverse and included the implementation of screening programs or tools, training clinicians to recognize and discuss psychosocial issues with patients and their families, and providing primary care professionals with community resource lists. Nine out of 10 studies included in the review reported favorable results. LIMITATIONS: Studies included in the review had relatively short follow-up periods, and the diversity of studies identified precluded the possibility of conducting a meta-analysis. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Findings suggest that interventions in pediatric primary care settings are feasible and can favorably affect clinical practices and families' outcomes.

No association found between traditional healer use and delayed antiretroviral initiation in rural Uganda.

Traditional healer and/or spiritual counselor (TH/SC) use has been associated with delays in HIV testing. We examined HIV-infected individuals in southwestern Uganda to test the hypothesis that TH/SC use was also associated with lower CD4 counts at antiretroviral therapy (ART) initiation. Approximately 450 individuals initiating ART through an HIV/AIDS clinic at the Mbarara University of Science and Technology (MUST) were recruited to participate. Patients were predominantly female, ranged in age from 18 to 75, and had a median CD4 count of 130. TH/SC use was not associated with lower CD4 cell count, but age and quality-of-life physical health summary score were associated with CD4 cell count at initiation while asset index was negatively associated with CD4 count at ART initiation. These findings suggest that TH/SC use does not delay initiation of ART.

Medical students as patients: implications of their dual role as explored in a vignette-based survey study of 1027 medical students at nine medical schools.

OBJECTIVE: Medical students experience a range of mental and physical illnesses during training and may encounter significant barriers in seeking health care. Little is known about the issues surrounding the dual role as both learner and patient when a medical student seeks care at his or her training institution. METHOD: A confidential survey examining medical students' health care needs, practices, and concerns was administered at 9 US medical schools. One part of the survey focused on responses to 4 medical student-patient vignettes. The vignettes systematically varied preexisting student vs preexisting patient status before assuming a medical student-patient role, and the vignettes also varied illness situations that were more vs less stigmatizing. Responses were analyzed using χ(2) and multivariate analysis of variance tests. RESULTS: A total of 1027 students participated. We found that students were more likely to accept the dual role as medical student-patient in vignettes depicting a preexisting patient role than a preexisting student role. Students sought to avoid the dual role as student-patient in the context of stigmatizing health concerns. Women students were more likely than men to reject the dual role in all cases. CONCLUSION: Medical students appear to be sensitive to the conflicts that may be associated with the dual role as both medical student and patient when seeking care at their training institution. Our data suggest the importance of substantive efforts to promote the health, interests, and well-being of medical student-patients.

Mexican immigrant women's perceptions of health care access for stigmatizing illnesses: a focus group study in Albuquerque, New Mexico.

This study examines attitudes of Mexican female immigrants to Albuquerque, New Mexico, regarding barriers to health care access in the United States and Mexico for stigmatizing and non-stigmatizing illnesses and moderating effects of social support. Native Spanish speakers conducted three focus groups (in Spanish) lasting two hours with seven to eight participants. Focus groups were transcribed, translated, and coded. Frequency data were calculated by number of times concepts or themes were raised. Comparisons of barriers to health care access were made between U.S. and Mexican cultures. The majority (86%) of comments on barriers for non-stigmatizing illnesses implicated U.S. culture; the majority (90%) for stigmatizing illnesses implicated Mexican culture. Social support for stigmatizing illnesses was discussed. Participants discussed important issues of health care access for stigmatizing illnesses that may have implications for this population's health status. Greater attention should be paid to stigma and social support in future empirical studies.

Medical student illness and impairment: a vignette-based survey study involving 955 students at 9 medical schools.

BACKGROUND: Physician impairment is defined by the presence of a physical, mental, or substance-related disorder that interferes with the ability to practice medicine competently and safely. The seeds of impairment may be sown early in adulthood, and medical students experience health issues that may receive insufficient attention in the context of a rigorous training period. Few empirical studies have examined the attitudes of medical students toward recognizing and acting upon signs of potentially impairing illnesses in peers. METHOD: Medical students at 9 medical schools were invited to participate in a written survey exploring personal health care issues during training. As part of this larger project, students were asked to imagine their response in 3 situations to a medical student who is discovered to have serious symptoms and potential impairment secondary to mental illness, substance abuse, or diabetes. RESULTS: Responses were gathered from 955 students (52% overall response rate). For all of the vignettes, "tell no one but encourage him/her to seek professional help" was the most prevalent reaction (45%, 53%, and 49%, respectively) as opposed to seek advice (37%, 35%, and 42%) and notify the Dean's office (18%, 12%, and 9%). Willingness to report varied by school, and women were somewhat less likely to formally report medical student illness. CONCLUSION: This study suggests that medical students attach great importance to preserving the confidentiality of fellow medical students who may experience even very severe symptoms. This pattern may have important implications for the early recognition and treatment of potentially impairing disorders. Greater attention to these issues may help assure the health of early career physicians as well as the many patients whose safety and well-being are entrusted to their care.