Driving to Reduce Socioeconomic Barriers to Latent Tuberculosis Infection Care: A Mobile Pediatric Treatment Program.

CONTEXT: Tuberculosis (TB) disease causes significant morbidity, mortality, and public health impacts. Prevention of latent tuberculosis infection (LTBI) in children reduces the burden of disease. PROGRAM: The Texas Children's Mobile Clinic Program's (TC-MCP's) mission is to provide high-quality health care to underresourced children within the community setting. The TC-MCP serves a large foreign-born pediatric population. The need for an LTBI treatment program arose when caring for this high-risk population. IMPLEMENTATION: The TC-MCP providers collaborated with nationally recognized pediatric TB experts as well as local health departments that provide medications free of cost. The TC-MCP placed tuberculin skin tests (TSTs) on patients with risk factors for TB. TST-positive patients had an interferon-γ release assay (IGRA) performed. IGRA-positive patients had a chest radiograph (CXR) obtained. Children with positive IGRA and normal CXR were included in the LTBI program, which consisted of TC-MCP outpatient visits and 12 once-weekly doses of isoniazid/rifapentine (3HP) provided by local health departments. RESULTS: From January 2018 to March 2020, 785 TC-MCP patients received TSTs, of which 38 (4.8%) were positive. An additional 7 positive TSTs were identified from outside facilities. In addition to the 45 positive TSTs, 4 TC-MCP patients with follow-up difficulties had IGRAs done as the initial test. Of these 49 IGRAs done, 13 patients had a positive IGRA. An additional 6 patients with positive IGRAs from outside facilities were identified. Nineteen patients (36.5%) were diagnosed with LTBI; of whom, 18 completed 3HP therapy through the TC-MCP. Eighty-three percent (15/18) completed at least 2 in-person visits. DISCUSSION: Underresourced children at higher risk for TB benefit from a mobile clinic's unique reach. By utilizing community partnerships, mobile clinics can successfully fill gaps in the health care system where marginalized populations may be missed.

Variations in Medical Students' Educational Preferences, Attitudes and Volunteerism during the COVID-19 Global Pandemic.

Public health crises require individuals, often volunteers, to help minimize disasters. The COVID-19 pandemic required such activation of individuals, but little is known about medical students' preferences of such engagement. We investigated potential variations in medical students' educational preferences, attitudes, and volunteerism during the COVID-19 pandemic based on socio-demographics to better prepare for future activation scenarios. A web-based, anonymous survey of U.S. medical students at a single institution was conducted in May 2020. Across four training year, 518 (68% response rate) students completed the survey. During the pandemic, 42.3% (n = 215) wanted to discontinue in-person clinical experiences, 32.3% (n = 164) wanted to continue, and 25.4% (n = 129) were neutral. There was no gender effect for engagement in volunteer activities or preference to engage in clinical activities during the pandemic. However, second-year (n = 59, 11.6%) and third-year students (n = 58, 11.4%) wanted to continue in-person clinical experiences at a greater proportion than expected, while a small proportion of fourth-year students (n = 17, 3.3%) wanted to continue, χ2(6) = 43.48, p < .001, φ = 0.29. Majority of respondents (n = 287, 55.5%) volunteered in clinical and non-clinical settings. A lower proportion of fourth-year (n = 12, 2.3%) and first-year students (n = 50, 9.7%) volunteered than expected. Likelihood to volunteer during a pandemic varied by gender, training year, and/or prior experience with disaster event depending on the type of volunteer-site setting. Our findings suggest socio-demographic factors may impact medical student engagement and volunteerism during a public health crisis. Educational leadership should be sensitive to such variations and can facilitate volunteer activities that allow student engagement during future pandemics.

Reaching Uninsured Overweight and Obese Children Through the FitKids Mobile Lifestyle Modification Program: Lessons Learned.

The US prevalence of childhood obesity remains high with ~ 1 in five children diagnosed with obesity, and rates of obesity are likely higher in uninsured and Medicaid populations than in those with private insurance. To understand the impact of an obesity intervention, an established mobile clinic program conducted a study to determine whether a FitKids Mobile Lifestyle Modification Program could reach overweight and obese uninsured children. Eighty-six children (ages 8-18 years) participated in the FitKids study over two trial periods. The first trial consisted of four total visits, but subsequent visits after the initial visit had poor turnout. Through telephonic interviews, parents described positive aspects of the program: (1) providers' individual attention to their child, (2) increased knowledge about obesity, nutrition, and diet, (3) and parent and child were motivated to be more active. The most common barriers noted for return visits were (1) personal/family factors, (2) scheduling issues, and (3) distance to the clinic. As quality improvement, for the second trial, total number of visits was reduced from 4 to 3 visits and reminder calls were instituted. Percentage of children who returned for the third visit (67.5% for Trial 1 and 62.5% for Trial 2) was not improved despite quality improvement interventions. Mobile clinics provide a unique solution to reach underserved overweight and obese children to help them create a more active and healthy lifestyle, but more research is needed to understand how best to optimize programs.

Lessons Learned from All for Them: Best Practices for a Cross-Collaboration Approach to HPV Vaccination in Public Schools.

The Community Preventive Services Task Force endorses vaccination programs in schools to increase access to vaccinations. However, implementing a school-based approach requires substantial coordination, planning, and resources. All for Them (AFT) is a multilevel, multicomponent approach to increase HPV vaccination among adolescents attending public schools in medically underserved areas in Texas. AFT comprised a social marketing campaign, school-based vaccination clinics, and school nurse continuing education. Process evaluation metrics and key informant interviews to understand experiences with AFT program implementation informed lessons learned. Lessons emerged in six domains: strong champion, school-level support, tailored and cost-effective marketing approaches, mobile provider collaboration, community presence, and crisis management. Strong support at district and school levels is vital for gaining principal and school nurse buy-in. Social marketing strategies are integral to program implementation and should be adjusted to maximize their effectiveness in motivating parents to vaccinate children against HPV, which also can be achieved through increased community presence of the project team. Preparing contingency plans and flexibility within the program can facilitate appropriate responses to provider restrictions in mobile clinics or in the event of unforeseen crises. These important lessons can offer useful guidelines for the development of prospective school-based vaccination programs.

Becoming a Doctor During a Pandemic: Impact on Medical Student Social Identity Formation.

The COVID-19 pandemic required modifications to undergraduate medical education that likely affected medical students' social identity formation (SIF). SIF is shaped by experiences throughout the medical education continuum. This commentary explores factors potentially affecting medical student SIF during the COVID-19 pandemic focusing on students' perceptions of being part of the healthcare team, their role in medicine, and their engagement during the pandemic. Based on such considerations, we propose that educators should aim to design effective learning environments to support a full educational experience that encompasses acquiring medical knowledge and building strong social identities even during a pandemic.

Implementing an inpatient integrative medicine consult service for children with pain: A qualitative analysis.

OBJECTIVES: Complementary and integrative medicine (CIM) therapies show clinical benefits with minimal side effects, yet challenges to effective integration in hospital settings remain. The current study aimed to better understand the process of integration of CIM therapies at a large urban pediatric hospital from the perspectives of providers, parents, and administrators. DESIGN: The study employed an applied medical ethnography. SETTING: The ethnography was conducted before, during, and after an Integrative Medicine Pain Consult Service (IM Pilot) was implemented at a large urban pediatric hospital during the spring of 2017. MAIN OUTCOME MEASURES: Fieldwork interviews, participant observations, and document review captured aspects of the integration of CIM over a 6-month study period. Ethnographic analysis included thematic content analysis. Participants included providers (n = 10), administrators (n = 5), and parents of patients (n = 11). RESULTS: Emergent themes from analysis of the interviews and field notes were organized according to the socio-ecological model. Themes included facilitating factors for CIM pain management at the intrapersonal and community levels (Alignment with Parental Perceptions of Child Needs and Provider Desire to Offer Care, Alignment of CIM with Spiritual Beliefs and Community Norms) and barriers at the interpersonal, organizational, and political levels (Inter-professional Challenges, Lack of Logistics in Place for Referrals and Triaging Patients with Pain, Lack of Remuneration/Insurance Reimbursement for Care). CONCLUSIONS: To address barriers, future efforts to implement integrative pain management programs in pediatric hospital settings may consider testing implementation strategies, including engaging program champions and family advocates, providing education on CIM professions and therapies to hospital staff, and billing for provider time rather than individual CIM therapies.

No Faculty Required: Use of a Health Literacy Low Inference Self-Assessment Measure to Promote Behavior Change.

OBJECTIVE: To determine if use of a health literacy low-inference, self-assessment measure (LISAM), promoted behavior change as measured by increased use of health literacy communication skills (HLCS). METHODS: The LISAM is a tool used by educators to self-assess their performances after giving a lecture. The tool is low inference because it self-assesses behaviors that are specific, with little room for subjectivity. Forty-four third-year medical students self-assessed HLCS using a LISAM modified to include health literacy communication skills (LISAM-HLCS).  Self-assessment followed participation in an audio recorded, standardized patient encounter and again after listening to the recording.  Students also created 3 written goals for improvement.  This session was repeated 1 week later. RESULTS: At Session 2, 71.4% of students met at least 2 of their 3 self-created objectives. The 3 most commonly created objectives were using teach-back, asking more open ended questions, and obtaining patient input into the management plan. Use of the LISAM increased HLCS use at Session 2 versus Session 1 as assessed by both students and study investigators (P < .05). CONCLUSIONS: Without faculty present, students met and adjusted objectives, catalyzing changes in HLCS. The LISAM-HLCS has the potential to empower students to improve communication skills and to reduce dependence on faculty observations.

Evaluating Partial Series Childhood Vaccination Services in a Mobile Clinic Setting.

This study aims to evaluate the cost-benefit of vaccination services, mostly partial series administration, provided by a mobile clinic program (MCP) in Houston for children of transient and low-income families. The study included 469 patients who visited the mobile clinics on regular service days in 2 study periods in 2014 and 836 patients who attended vaccination events in the summer of 2014. The benefit of partial series vaccination was estimated based on vaccine efficacy/effectiveness data. Our conservative cost-benefit estimates show that, compared with office-based settings, every dollar spent on vaccination by the MCP would result in $0.9 societal cost averted as an incremental benefit in regular service days and $3.7 during vaccination-only events. To further improve the cost-benefit of vaccination services in the MCP, decision-makers and stakeholders may consider improving work efficiency during regular service days or hosting more vaccination events.

A Novel Interprofessional Mock Clinic Workshop for Medical Students With Orthotics and Prosthetics Students.

Introduction: Medical school education on orthotics and prosthetics (O&P) is limited, and O&P students receive limited education on performing comprehensive histories and physicals (H&Ps). This interprofessional workshop brings medical and O&P students together in a mock clinical setting. Students from one profession appraise the relationship of their scope/role to those of students of the other profession. Methods: Third-year medical students, second-year O&P students, and O&P patients participated in a 3-hour workshop. Students partnered into groups and rotated among stations performing patient history, physical exam, and O&P assessment. As a medical or O&P student completed the H&P, she or he explained the process to the student of the other profession. Each group assessed two patients and then presented one to a physical medicine and rehabilitation (PM&R) attending physician. The workshop concluded with a feedback session. Results: Immediate feedback was positive. Medical students, O&P students, PM&R physicians, and patients all commented favorably. In the workshop's first year, there were 19 responding students (10 medical, nine O&P); 68.4% said that the clinical session was better than expected, 73.7% were satisfied with the overall event, and 73.7% felt they were likely to use what they had learned in clinical practice. Feedback from learners included requesting more time for students to interact with each other after the mock clinic, sending preparation materials before the session, and focusing the medical student H&P on the musculoskeletal exam. Discussion: This workshop was well received by participants. Their feedback will help to continue and expand this collaboration.

Employing Evidence in Evaluating Complementary Therapies: Findings from an Ethnography of Integrative Pain Management at a Large Urban Pediatric Hospital.

BACKGROUND: Complementary and Integrative Medicine (CIM) shows positive clinical benefit with minimal side effects, yet, challenges to effective integration of CIM providers in biomedical health care settings remain. This study aimed to better understand the role evidence played in the process of integration of complementary therapies into a large urban pediatric hospital from the perspective of patients, caregivers, providers, and administrators through applied medical ethnography. METHODS: An ethnography was conducted over the course of 6 months in a large urban pediatric hospital in the Southern United States. At the time, the hospital was piloting an integrative medicine (IM) pain consult service. Purposive sampling was used to select providers, patients, administrators, and caregivers to follow as they engaged with both the preexisting pain service and pilot IM pain services. Field observation and interviews were conducted with 34 participants. Thematic content analysis was used to analyze field notes, interview transcripts, and documents collected. FINDINGS: Analysis of the data revealed five themes regarding the role of evidence in the process of integration: Anecdotal Evidence and Personal Experience Effecting CIM Use, Open to Trying Whatever Works, Resistance to the Unfamiliar, Patients and Parents Trusting Doctors as Experts, and Importance of Scientific Evidence to Biomedicine. All themes address the role of evidence in relationship to acceptance of complementary therapies and correspond with three thought processes: critical thinking, relying on others for evidence, and reactionary thinking. CONCLUSION: Both scientific and anecdotal evidence informed CIM use in this context. Biomedical environments seeking to integrate CIM into pain treatment regimens will need to engage all relevant stakeholders in building education, clinical training, and research programs that are critically informed about the context and evidence for CIM.

Addressing Pain With Inpatient Integrative Medicine at a Large Children's Hospital.

BACKGROUND: Pediatric integrative medicine (IM) includes the use of therapies not considered mainstream to help alleviate symptoms such as pain and anxiety. These therapies can be provided in the inpatient setting. METHODS: This 10-week study involved the integration of acupuncture, biofeedback, clinical hypnotherapy, guided imagery, meditation, and music therapy to address pain in children admitted to a large US children's hospital. RESULTS: Of 51 patients enrolled, 60% of the patients, 66% of their mothers, and 56% of their fathers used CAM (complementary and alternative medicine) in the preceding 1 year. Although 51 families requested integrative therapies, only 18 patients received them because of inadequate provider availability. All recorded pain scores improved with integrative therapies. One parent reported a possible side effect of irritability in the child after clinical hypnotherapy while 5 children reported opiate side effects. All participating families interviewed responded that IM services helped their child's pain and helped their child's mood, and that our hospital should have a permanent IM consult service. CONCLUSION: Integrative therapies can be helpful to address pain without significant side effects. Further studies are needed to investigate the integration, cost, and cost-effectiveness of integrative therapies in pediatric hospitals.

Complementary and integrative medicine attitudes and perceived knowledge in a large pediatric residency program.

OBJECTIVE: There is limited formal complementary and alternative medicine (CAM)/integrative medicine (IM) training in most US pediatric residency programs. Not surprisingly, the AAP Fellows survey #49 demonstrated that pediatricians in residency training and those younger than 42 years old reported less knowledge of CAM than their counterparts. The purpose of this study was to assess pediatric residents' attitudes toward CAM and IM, personal use of CAM, perceived knowledge gaps, and preferred methods of delivery for IM education in a large pediatric residency program. METHODS: A 20-question anonymous, voluntary electronic survey was sent to all categorical and combined program pediatric residents at a pediatric residency program in Texas. RESULTS: Eighty of 177 pediatric residents completed the survey. Eighty-three percent of respondents reported that patients have asked them about complementary and integrative medicine, and 88% reported that they would like to expand their knowledge on CAM/IM. Lack of knowledge was the top barrier to residents' incorporation of complementary and integrative medicine into their practice. Preferred methods of education delivery were reported as exposure to complementary and integrative medicine providers and noon conference lectures. CONCLUSIONS: Residents in this large pediatric residency program recognize their knowledge gaps and wish to improve their understanding of complementary and integrative medicine. A formal IM curriculum could bridge knowledge gaps and help residents feel more comfortable discussing IM with patients and their families.

Pediatric Integrative Medicine: Vision for the Future.

Pediatric integrative medicine (PIM) is of significant interest to patients, with 12% of the general pediatric population and up to 80% of children with chronic conditions using PIM approaches. The field of PIM has evolved over the past 25 years, approaching child health with a number of guiding principles: preventive, context-centered, relationship-based, personalized, participatory, and ecologically sustainable. This manuscript reviews important time points for the field of PIM and reports on a series of meetings of PIM leaders, aimed at assessing the state of the field and planning for its future. Efforts in the first decade of the 2000s led to increased visibility in academic and professional pediatric organizations and through international listservs, designed to link those interested in and practicing PIM, all of which continue to flourish. The PIM leadership summits in recent years resulted in specific goals to advance PIM further in the following key areas: research, clinical practice, professional education, patient and family education, and advocacy and partnerships. Additionally, goals were developed for greater expansion of PIM professional education, broader support for pediatric PIM research, and an expanded role for PIM approaches in the provision of pediatric care.

Medical and Dental Students' Perceptions and Attitudes towards Interprofessional Clinical Education.

This article was migrated. The article was marked as recommended. Purpose: Interest and expansion of interprofessional education (IPE) has increased tremendously over the last decade due to need and regulatory requirements. Methods: Third-year medical students and third and fourth-year dental students participated in a combined IPE experience at a dental assessment clinic. All participating students completed the Readiness for Interprofessional Learning Scale (RIPLS) Questionnaire before the session, and medical students completed an evaluation after the session. Results: All students agreed that IPE is important and needed for the development of skills, and they see benefit to shared learning. The only RIPLS question in which students did not agree was "Clinical problem solving can only be learnt effectively with students/ professionals from own school/organization." The dental students agreed with this more than medical students (p=0.04). Age of medical and dental students was related with outcomes of RIPLS questions 2, 7, 14, and 16 (p=0.03, 0.02, 0.03, and 0.02, respectively). Older participants from both schools tended not to agree with statements related to importance of working together benefiting patients, improving working relationships, welcoming the opportunity to work on small group projects with other health/social care students, and whether shared learning/practice will help clarify the nature of patients' problems. Medical student evaluations of the dental IPE experience were very positive, and mild changes in the curriculum improved medical student perception of the experience from year 1 to 2. Conclusion: Guidelines and standardized curricula could help medical and dental school faculty create clinically appropriate and effective IPE interactions for learners of all ages.

Correction: Esparham, A., et al., Pediatric Integrative Medicine: Vision for the Future. Children, 2018, 5, 111.

The authors wish to make the following corrections to their paper [...].

Utilizing Lean Principles to Improve Immunization Administration Efficiency in a Pediatric Mobile Clinic Program.

INTRODUCTION: Mobile clinics are vital health care delivery systems because they provide care to those who may not have access otherwise. Unfortunately, clinic flow on mobile clinics is often chaotic and inherently inefficient. Lean is a customer-centric methodology used in industries like health care to continuously improve processes by eliminating waste. The purpose of this project was to use lean principles to improve efficiency, as measured by total time spent receiving services, so that more underserved patients could receive needed immunizations. METHODS: Using a certified lean expert, lean principles were applied to the mobile clinic program to uniformly organize the program, simplify registration processes, and standardize clinic procedures. Time study data were collected prospectively on a total of 309 patients for 2-week periods both before and after application of lean principles. Staff used a standardized time study form to record patient visit times. Pre- and postintervention data were analyzed using unpaired t tests and nonparametric Mann-Whitney tests as deemed appropriate. RESULTS: Using lean principles significantly reduced total times spent for 1-, 2-, and 4-children families. Wait times for 1- and 4-children families were also significantly decreased. Lastly, times spent on board the mobile clinic to receive immunizations for 1- and 3-children families were significantly decreased. CONCLUSION: Application of lean principles can improve efficiency by decreasing total time spent for patients receiving vaccine services on pediatric mobile clinics.

Complementary and Alternative Medicine Use in Uninsured Children in Texas.

Use of complementary and alternative medicine (CAM) among US children is 12% according to the 2012 National Health Interview Study. Certain pediatric populations have higher CAM use. We studied an uninsured population because limited access to care likely results in higher CAM use. We surveyed 250 uninsured patients in a free pediatric mobile clinic program. In the largely Hispanic population, rate of CAM use in the preceding 12 months was 45% among children and 59% among parents. Ninety-one percent of children who used CAM had parents who used CAM while only 32% of parents used CAM for themselves but did not use CAM for their children ( P < .001). Seven parents (3%) and 4 children (2%) had ever discussed their CAM use with a physician. Since CAM use is significant in this uninsured population and families do not generally discuss CAM with physicians, health care providers must ask about CAM use and provide guidance.

Survey of Complementary and Alternative Medicine (CAM) Services in Freestanding US Children's Hospitals.

Complementary and alternative medicine (CAM) use among US children in 2012 was 11.6%, and studies show CAM use as high as 76% in certain pediatric populations. Children's hospitals offer varied CAM services. This survey aimed to identify CAM services offered, the structure of CAM departments, and supplement use policies in freestanding US children's hospitals. In our survey, 92% of responding children's hospitals offered CAM services, and 38% had hospital-based CAM centers; 60% of responders had policies for supplement use during hospitalization, whereas only 40% had policies for supplement use surrounding surgery. CAM services are widely offered in freestanding US children's hospitals, but most do not have CAM departments. Many hospitals do not have written policies about supplement use. A better understanding of CAM services, programs, and supplement use policies are needed to bring more coordinated services and safer policies to children's hospitals.

The Current Evidence of Integrative Approaches to Pediatric Asthma.

Asthma is a complex, multifactorial, and inflammatory chronic condition, and many children who are diagnosed with asthma integrate complementary therapies into their overall care. Due to the chronic nature of asthma, potentially negative side effects of long-term use of allopathic medications, and desire for natural approaches, patients and their families turn toward complementary therapies. Up to 89% of parents use complementary and alternative medicine (CAM) to treat their child's asthma. This article reviews the current evidence on the most commonly used complementary therapies for pediatric asthma.

Chronic Health Conditions, Physical Activity and Dietary Behaviors of Bhutanese Refugees: A Houston-Based Needs Assessment.

Bhutanese refugees resettling in the U.S. face many challenges including several related to health and health care. Limited health literacy and the relatively complicated US health care system may contribute to health disparities as well. A health assessment was conducted on adult refugees in Houston, Texas to provide healthcare providers, community organizations, and stakeholders baseline data to plan programs and interventions. A convenience sample of 100 participants had a mean age of 38.37 years, 56 % where males, and almost 80 % did not have high school level education. High blood pressure (27 %), dizziness (27 %), and arthritis (22 %) were the commonly identified chronic health conditions and trouble concentrating (34 %) and fatigue (37 %) were also reported. Sixty-two percent of the respondents reported that they consume recommended servings of fruits and vegetables and 41 %reported that they were currently getting at least 20-30 min of aerobic exercise per day. The assessment concluded with recommendations on how better provide care and services for the refugees.