Knowledge and use of ethnomedical treatments for asthma among Puerto Ricans in an urban community.

PURPOSE: Puerto Ricans have higher lifetime and current asthma prevalence than other racial and ethnic groups in the United States. A great many Hispanics use ethnomedical therapies for asthma. This study elicited participant knowledge of ethnomedical therapies, developed a typology of the therapies, and considered whether some types are used or deemed efficacious based, in part, on information source. METHODS: Eligible participants were randomly selected from the medical records of an inner-city primary care clinic serving a predominantly Hispanic community in Buffalo, New York. Thirty adult Puerto Ricans who had asthma or were care-givers of children with asthma were interviewed in person using a semistructured instrument. Qualitative data analysis followed a content-driven immersion-crystallization approach. Outcome measures were ethnomedical treatments for asthma known to participants, whether these treatments were used or perceived effective, and the participant's information source about the treatment. RESULTS: Participants identified 75 ethnomedical treatments for asthma. Behavioral strategies were significantly more likely to be used or perceived effective compared with ingested and topical remedies (P <.001). Among information sources for ingested and topical remedies, those recommended by community members were significantly less likely to be used or perceived effective (P <.001) compared with other sources. CONCLUSIONS: This sample of Puerto Ricans with a regular source of medical care was significantly more likely to use or perceive as effective behavioral strategies compared with ingested and topical remedies. Allopathic clinicians should ask Puerto Rican patients about their use of ethnomedical therapies for asthma to better understand their health beliefs and to integrate ethnomedical therapies with allopathic medicine.

The implementation of Good For The Neighborhood: a participatory community health program model in four minority underserved communities.

To describe the participatory approach used to develop "Good For The Neighborhood" (GFTN), a community program to improve the health of four underserved communities. A core program was developed involving a "park and stay" approach to impact four underserved predominately minority communities (two predominately African American, 1 predominately Latino, and the Seneca Nation of Indians). The core program includes health screenings, risk assessments, health education, and exposure to health services. An extensive tracking and evaluation system was developed to determine participation and impact on the community. Multi-methods (key informant interviews, focus groups, surveys) were implemented to gain feedback from community partners and participants as to how to adopt the program to meet the needs of the community. GFTN has been sustained for over 3 years and has reached over 3,500 predominately minority individuals in four communities with 1/3 of participants engaging regularly in the program. The program has evolved in the four communities to meet specific needs. A "park and stay" approach in partnership with the community has led to a strong program that community partners and residents embrace. Community ownership and social networking, including word-of-mouth from residents is essential to establishing a successful program.

Improving Cancer Screening Rates in Primary Care via Practice Facilitation and Academic Detailing: A Multi-PBRN Quality Improvement Project.

PURPOSE: In the United States, cancer screening rates are often below national targets. This project implemented practice facilitation and academic detailing aimed at increasing breast, cervical, and colorectal cancer screening rates in safety-net primary care practices. METHODS: Three practice-based research networks across western and central New York State partnered to provide quality improvement strategies on breast, cervical, and colorectal cancer screening. Pre/postintervention screening rates for all participating practices were collected annually, as were means across all practices over 7 years. Simple ordinary least squares linear regression was used to calculate the trend for each cancer type and test for statistical significance (ie, P≤0.05), using the ordinal time point as a fixed effect. RESULTS: An overall increase in mean screening rates was seen over the duration of this project for colorectal (24.6% preintervention to 48.0% in year 7 of intervention; P<0.001) and breast cancer (37.0% preintervention to 48.6% in year 7; P=0.460). Mean cervical cancer screening rates decreased (35.5% preintervention to 31.4% in year 7; P=0.209). Success in increasing screening rates varied across regions of New York State. CONCLUSIONS: Practice facilitation and academic detailing were successful in significantly increasing, on average, colorectal cancer screening rate. Cervical cancer screening showed an overall decrease, likely due to difficulties for primary care practices in tracking and implementation, as many patients seek this service at outside gynecology facilities. Regional differences, guideline changes, and practice reorganization each may have played a part in observed trends. A standardization of queries being used to pull screening rates is an important step in increasing the reliability of these data.

Increasing Breast, Cervical, and Colorectal Cancer Screenings: A Qualitative Assessment of Barriers and Promoters in Safety-Net Practices.

PURPOSE: Breast, cervical, and colorectal cancer screening rates are suboptimal in underserved populations. A 7-year quality improvement (QI) project implemented academic detailing and practice facilitation in safety-net primary care practices to increase cancer screening rates. This manuscript assesses barriers and promoters. METHODS: Primary care practices providing care to underserved patients were recruited in New York cities Buffalo, Rochester, and Syracuse. Enrollment totaled 31 practices, with 12 practices participating throughout. Annually, each practice received 6 months of practice facilitation support for development and implementation of evidence-based interventions to increase screening rates for the three cancer types. At the end of each practice facilitation period, focus groups and key informant interviews were conducted with participating personnel. Content analysis was performed annually to identify barriers and promoters. A comprehensive final analysis was performed at project end. RESULTS: Barriers included system-level (inconsistent communication with specialists, electronic health record system transitions, ownership changes) and practice-level challenges (staff turnover, inconsistent data entry, QI fatigue) that compound patient-level challenges of transportation, cost, and health literacy. Cyclical barriers like staff turnover returned despite attempts to resolve them, while successful implementation was promoted by reducing patients' structural barriers, adapting interventions to existing practice priorities, and enacting officewide policies. During the QI project, practices became aware of the impact of social determinants of health on patients' screening decisions. CONCLUSIONS: The project's longitudinal design enabled identification of key barriers that reduced accuracy of practices' screening rates and increased risk of patients falling through the cracks. Identified promoters can help sustain interventions to increase screenings.

Impact of COVID-19 on Screening Rates for Colorectal, Breast, and Cervical Cancer: Practice Feedback From a Quality Improvement Project in Primary Care.

PURPOSE: Three New York State practice-based research networks provided quality improvement strategies to improve screening rates for breast, cervical, and colorectal (BCC) cancers in safety-net primary care, over 7 years. In the final year (Y7), the United States experienced the COVID-19 pandemic. The impact of the COVID-19 pandemic on BCC cancer screening rates was assessed qualitatively. METHODS: A total of 12 primary care practices participated in Y7 of the quality improvement project. BCC cancer screening rates at year beginning and end were assessed. Practice staff were asked about how COVID-19 impacted screening. Average pre/postintervention screening rates and qualitative thematic analysis regarding how COVID-19 impacted cancer screening were ascertained. RESULTS: In Y7, there was an increase in breast cancer and a decrease in colorectal and cervical cancer screening rates compared to the previous project year. Many practices were able to continue pre-COVID-19 cancer screening processes. Overall, practices reported loss of staff, changes in data entry, and a shift from preventive screening to care of sick patients. Telehealth was vital for practices to continue serving patients but had a less positive impact on patients with financial/technological disadvantages. BCC cancer screenings were impacted at various levels. CONCLUSIONS: The COVID-19 pandemic negatively impacted primary care practice cancer screening; however, some practices were able to mitigate effects by shifting focus to processes supporting screening outside of in-person office visits.

"Bashing" of medical specialties: students' experiences and recommendations.

BACKGROUND AND OBJECTIVES: Exposure to non-constructive criticism of medical specialties is believed to be fairly common among medical students. Better understanding of this "bashing" phenomenon is needed to promote greater professionalism in medical education and student interest in primary care careers. This study examines exposure and reactions to bashing among third-year medical students in a public university. METHODS: A survey assessing amount, sources, targets, and nature of perceived bashing was completed by 105 students. Three open-ended questions elicited students' experiences, opinions, and recommendations. RESULTS: Students perceived that bashing of other specialties occurred during all clerkships; the most were perceived during the surgery clerkship, for which 87.5% reported such bashing. Specialties perceived as the object of bashing were family medicine (72%), general internal medicine (40%), psychiatry (39%), and general surgery (36%). Sixty-seven percent of students reported personally receiving non-constructive criticism about their preferred specialty. Seventy-nine percent believed bashing was unprofessional behavior. Strategies suggested by respondents to decrease bashing included increasing awareness, highlighting the interdisciplinary nature of medicine, and evaluating professionalism. CONCLUSIONS: Medical students perceived bashing of medical specialties, recognized it as unprofessional behavior, and would be receptive to interventions to reduce bashing. Findings suggest a need to address bashing as part of professionalism curricula in medical training.

Community Engagement in Academic Health Centers: A Model for Capturing and Advancing Our Successes.

Community engagement (CE) has come to the forefront of academic health centers' (AHCs) work because of two recent trends: the shift from a more traditional 'treatment of disease' model of health care to a population health paradigm (Gourevitch, 2014), and increased calls from funding agencies to include CE in research activities (Bartlett, Barnes, & McIver, 2014). As defined by the Centers for Disease Control and Prevention, community engagement is "the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people" (Centers for Disease Control and Prevention (CDC), 1997, p. 9). AHCs are increasingly called on to communicate details of their CE efforts to key stakeholders and to demonstrate their effectiveness. The population health paradigm values preventive care and widens the traditional purview of medicine to include social determinants of patients' health (Gourevitch, 2014). Thus, it has become increasingly important to join with communities in population health improvement efforts that address behavioral, social, and environmental determinants of health (Michener, et al., 2012; Aguilar-Gaxiola, et al., 2014; Blumenthal & Mayer, 1996). This CE can occur within multiple contexts in AHCs (Ahmed & Palermo, 2010; Kastor, 2011) including in education, clinical activities, research, health policy, and community service.

Breast and cervical cancer screening for Puerto Ricans, African Americans, and non-Hispanic whites attending inner-city family practice centers.

OBJECTIVES: Disparities exist for breast and cervical cancer screening among racial/ ethnic groups and low-income women. This study determines racial/ethnic variation in: 1) staging readiness for mammography, Pap smears, and clinical breast exam (CBE); 2) identifying patterns of adherence; and 3) determining sociodemographics associated with compliance with all three exams. DESIGN: Cross-sectional. SETTING: Two urban family medicine clinics. PATIENTS: A consecutive sample of 343 women presenting for care. INTERVENTIONS: Women were staged (maintainers, actors, contemplators, precontemplators, relapse contemplators, and relapse precontemplators) according to self-reported receipt of mammography, CBEs, and Pap smears. MAIN OUTCOME MEASURES: Adherence across exams was assessed. Sociodemographics were compared among racial/ethnic groups for women adherent with all three exams. RESULTS: Sixty-one percent were adherent with mammography, 93% with Pap smears, and 67% with CBEs. Thirty percent were contemplating mammography. Fifty-eight percent of Puerto Rican women were adherent with CBEs compared to 68.6% of African American and 78.5% of non-Hispanic White women. Puerto Rican women were less likely to be maintainers of CBE and more likely to be precontemplators and relapsers than non-Hispanic White women (P=.004). Forty-eight percent were adherent with all three exams. Puerto Rican women compliant with all three screens were younger and less educated than African American and non-Hispanic White CONCLUSIONS: Racial/ethnic differences in screening patterns exist among women attending urban family practice centers. Primary care providers must be culturally sensitive when recommending screening and can use staging as a tool to target women most receptive to intervention.

Self-report and primary care medical record documentation of mammography and Pap smear utilization among low-income women.

PURPOSE: To determine whether self-report of mammography and Pap smear utilization was accurate and to determine whether racial/ethnic differences existed. METHODS: Face-to-face surveys were administered to 314 consecutively selected women over 40 attending two low-income inner-city family practice sites. Medical records were reviewed for documentation of mammography and Pap smear utilization. Level of agreement between self-report and chart review was reported. Sensitivity, specificity, positive predictive value and negative predictive value were calculated. MAIN FINDINGS: Puerto Rican women had lower income levels and were less educated than African-American and non-Latina white women. Self-report of mammograms and Pap smears were higher than medical record documentation. Level of agreement was higher for more recent tests. Negative predictive values for mammography were high (75-95.5%). Lower sensitivity, specificity, positive predictive value and negative predictive value for mammography were seen among Puerto Rican women compared to African-American and non-Latina white women. CONCLUSIONS: High negative predictive values suggest that asking women about mammography use may be an inexpensive, easy intervention in the primary care setting to increase screening among women currently not being screened by increasing conversations between patients and providers to address personal barriers to screening.

Building community research capacity: process evaluation of community training and education in a community-based participatory research program serving a predominantly Puerto Rican community.

BACKGROUND: Education and training build community research capacity and have impact on improvements of health outcomes. OBJECTIVES: This manuscript describes the training and educational approaches to building research capacity that were utilized in a community-based participatory research program serving a Puerto Rican population and identifies barriers and strategies for overcoming them. METHODS: A process evaluation identified a multitiered approach to training and education that was critical to reaching the broad community. RESULTS: This approach included four major categories providing a continuum of education and training opportunities: networking, methods training, on-the-job experience, and community education. Participation in these opportunities supported the development of a registry, the implementation of a survey, and two published manuscripts. Barriers included the lack of a formal evaluation of the education and training components, language challenges that limited involvement of ethnic groups other than Puerto Ricans, and potential biases associated with the familiarity of the data collector and the participant. The CBPR process facilitated relationship development between the university and the community and incorporated the richness of the community experience into research design. Strategies for improvement include incorporating evaluation into every training and educational opportunity and developing measures to quantify research capacity at the individual and community levels. CONCLUSIONS: Evaluating training and education in the community allows researchers to quantify the impact of CBPR on building community research capacity.

The impact of provider knowledge and attitudes toward national asthma guidelines on self-reported implementation of guidelines.

This study determines the impact of provider knowledge and attitude on implementation of guidelines: spirometry, peak flows, patient assessments, action plans, severity assessment, and anti-inflammatories. A self-administered survey conducted in academic family practice sites in Buffalo, NY assessed knowledge, self-reported use, and perceived usefulness. Knowledge was associated with regular use of peak flows (p = 0.048) and anti-inflammatories (p = 0.01). Positive attitude was associated with regular use of spirometry (p = 0.03), peak flows (p < or = 0.001), patient assessments (p = 0.02), action plans (p = 0.046), anti-inflammatories (p < or = 0.001), and severity assessment (p < or = 0.001). Perceived usefulness is critical to implementing asthma guidelines. Interventions to improve provider adherence must address attitude.

Encouraging a systems approach for adherence to national asthma guidelines.

PURPOSE: There is a lack of information in the literature reflecting systems effects on adherence to national asthma guidelines. The purpose of this pilot study is to provide a descriptive account of the preparedness of academic primary care sites to follow national asthma guidelines related to spirometry, peak flow meters, standard history forms, severity assessment, follow-up assessment sheets, patient self-assessment sheets, and asthma action plan templates. METHODS: This was a cross-sectional descriptive study. A short survey was mailed to medical directors on behalf of primary care academic clinical sites to assess the availability of guideline tools in their practices. Medical directors were also asked to rate their perception of how essential the guidelines were in the management of asthma. RESULTS: Medical directors agreed that the guideline tools were essential in managing asthma. However, with the exceptions of peak flow meters and standard history forms, most sites were not equipped with these tools for providers to use. CONCLUSIONS: The findings highlight the importance of the practice environment on the implementation of national asthma guidelines and encourage larger studies to include an assessment of the systems in place to enable guideline adherence. By taking systems into account, interventions may be potentially much more effective in improving the quality of care.