Use of Abortion Services in Massachusetts After the Dobbs Decision Among In-State vs Out-of-State Residents.

This cohort study compares observed vs expected abortion counts after Dobbs in Massachusetts among in-state vs out-of-state residents.

Effectiveness of a New Clinical and Communication Curriculum for Medical Students: Result of a Double-Blinded Randomized Controlled Educational Trial.

OBJECTIVES: To improve 4 skills (communication, history-taking, past history-taking, and documentation) in medical students, we designed and pilot-tested a curriculum to teach a sample of Year 4 (Y4) students these skills and compared the clinical performance of these students with students not receiving the intervention. METHODS: The study focused on the new curriculum's effectiveness in enhancing students' performance of these skills. To minimize exposure across groups, participants were divided into intervention and control groups at random and placed in various classrooms. We evaluated each group's clinical competency 3 times: prior to the intervention, 9 weeks afterward, and 2 years later. RESULTS: There was no difference at baseline between the 2 groups. Immediately following the intervention, the mean score of the intervention group's skills was significantly higher than before and higher than the control group in each clinical skill. The performance difference between the 2 groups was maintained for 2 years following the intervention. CONCLUSIONS: Following a 9-week curriculum, evaluators rated students' performance higher than their counterparts who learned these skills through standard informal exposure in the clinical setting. The fact that this performance advantage was maintained for 2 years following the intervention is a testament to the durability of the intervention and the value of dedicated training in these critical areas at an early point in students' clinical careers.

Longer Times to Delivery of Otolaryngology Care for Patients With Limited English Proficiency.

OBJECTIVE: Limited English proficiency (LEP) is known to contribute to poorer health outcomes and delays in management. However, to our knowledge, no other studies have explored the impact of LEP on delays to care within otolaryngology. This study aims to investigate the relationship between LEP and the time to delivery of otolaryngology care. METHODS: We retrospectively reviewed 1125 electronic referrals to an otolaryngologist from primary care providers at 2 health centers in the greater Boston area, between January 2015 and December 2019. Multivariable logistic regression analyses were conducted to determine if patient LEP status (preferred language non-English and language interpreter use) has an impact on total time to appointment (TTTA). RESULTS: Patients with non-English preferred languages were 2.6 times more likely to experience extended TTTA (odds ratio [OR] = 2.61, 95% confidence interval [CI] = 1.99-3.42, p < .001) relative to English-speaking patients. Patients who required interpreter use were 2.4 times more likely to experience extended TTTA (OR = 2.42, 95% CI = 1.84-3.18, p < .001) relative to patients who did not require an interpreter. There was no difference in age, sex, insurance type, education level, or marital status. TTTA did not vary by diagnosis category (p = .09). DISCUSSION: LEP is an important factor that influences the time to appointment in our cohort. Notably, the impact of LEP on appointment wait times was independent of diagnosis. IMPLICATIONS FOR PRACTICE: Clinicians should recognize LEP as a factor that can impact the overall delivery of care in otolaryngology. Specifically, mechanisms to streamline care for LEP patients should be considered.

Undergraduate Medical Education Reform in Viet Nam for a Primary Health Care Workforce.

Strong primary health care (PHC) systems require a robust PHC workforce. Traditionally, medical education takes place in academic medical centres that favour subspecialty care rather than PHC settings. This may undervalue primary care as a career and contribute to a shortage of PHC workers. However, designing undergraduate medical education curricula that incorporate early experiences in clinical care delivery at PHC sites remains a challenge, including in many low- and middle-income countries (LMICs). This paper describes how a collaboration between Harvard Medical School and five medical schools in Vietnam, and in-country collaborations among the Vietnamese medical schools, facilitated curricular innovation and co-creation of coursework relevant to PHC through the development of a Practice of Medicine (POM) course. The collaboration implemented a technical assistance strategy consisting of in-person workshops, focused virtual consultations, on-site 'office hours', site visits and observations to each of the five medical universities, and immersion trips to support the creation and implementation of the POM course. A pilot program was started at a single site and then scaled nationally using local customisation, experience, and expertise utilising a train-the-trainers approach. As a result, five new POM courses have been developed by five Vietnamese institutions. Fifty Vietnamese faculty received training to lead the POM course development, and 228 community-based preceptors have been trained to teach students at PHC sites. A total of 52 new PHC and community-based clinical training sites have been added, and 3,615 students have completed or are currently going through a POM course. This experience can serve as a model for future academic collaborations to support the development of a robust PHC workforce for the 21st century.

Barriers and Pathways to Providing Long-Acting Reversible Contraceptives in Massachusetts Community Health Centers: A Qualitative Exploration.

CONTEXT: Structural barriers to the provision of long-acting reversible contraceptive (LARC) methods at community health centers have been identified in quantitative research, but the processes and behaviors by which center staff respond to these barriers are poorly understood. METHODS: Focus group discussions were conducted with clinical, support and administrative staff at three Massachusetts community health centers between April 2014 and January 2015. The centers were purposively selected to constitute a sample with diverse characteristics. Overall, 57 individuals participated in seven focus groups. Data were analyzed inductively using a modified grounded theory approach, and typical pathways to obtaining LARC methods were identified. RESULTS: Community health center staff provided contradictory descriptions of their facilities' protocols and practices. Patients' pathways to obtaining LARC methods were idiosyncratic and clinician-dependent, and resulted in patients' waiting between one week and three months to receive their preferred method. Providers' individual comfort with and perceived competence in contraceptive counseling often shaped patients' pathways to care. Overall, staff did not consider same-day insertion of LARC methods a feasible goal. Counseling protocols, insurance verification practices and logistical challenges in ordering and stocking devices were identified as major barriers to timely placement. CONCLUSIONS: Efforts to improve LARC provision at community health centers should include the education of staff in how expeditious placement constitutes clinical best practice and the implementation of infrastructural changes to support staff in efficiently counseling patients, scheduling placements and procuring LARC devices regardless of patients' insurance coverage.

Mentoring Across Differences.

Introduction: Effective mentoring can contribute to wellness and career growth and satisfaction. However, the same social forces and interpersonal dynamics affecting all relationships can compromise mentoring relationships. This is especially true when there are issues that are compounded by structural disadvantage due to racism, gender bias, social class, and other discriminatory factors. The Mentoring Across Differences (MAD) sessions are a workshop designed to develop and nurture skills, tools, self-awareness, and mindful practice in mentors and mentees. The workshop encourages participants to gain confidence in navigating differences across a variety of domains. Methods: We designed interactive sessions for faculty as part of a nine-part training series on mentoring in an academic setting. Teaching methods drew from adult learning theory. We used cases distilled from real teaching and mentoring experiences to trigger discussion and activate emotion and intrinsic motivation. Participants' prior knowledge and experience were drawn on to cocreate knowledge through small-group peer learning. Results: As part of a course, 167 participants completed the sessions; several hundred more people participated in them in faculty development venues. Participants highly rated the open discussions regarding differences and enhanced awareness of their assumptions, specifically highlighting knowledge and tools addressing bias in their roles as mentors and teachers. Discussion: The MAD sessions function both as an important module in a comprehensive mentoring curriculum and as stand-alone sessions. They fill a critical need of faculty and training institutions to explore difference in order to foster diversity and inclusion.

Blueprint for an Undergraduate Primary Care Curriculum.

In light of the increasing demand for primary care services and the changing scope of health care, it is important to consider how the principles of primary care are taught in medical school. While the majority of schools have increased students' exposure to primary care, they have not developed a standardized primary care curriculum for undergraduate medical education. In 2013, the authors convened a group of educators from primary care internal medicine, pediatrics, family medicine, and medicine-pediatrics, as well as five medical students to create a blueprint for a primary care curriculum that could be integrated into a longitudinal primary care experience spanning undergraduate medical education and delivered to all students regardless of their eventual career choice.The authors organized this blueprint into three domains: care management, specific areas of content expertise, and understanding the role of primary care in the health care system. Within each domain, they described specific curriculum content, including longitudinality, generalism, central responsibility for managing care, therapeutic alliance/communication, approach to acute and chronic care, wellness and prevention, mental and behavioral health, systems improvement, interprofessional training, and population health, as well as competencies that all medical students should attain by graduation.The proposed curriculum incorporates important core features of doctoring, which are often affirmed by all disciplines but owned by none. The authors argue that primary care educators are natural stewards of this curriculum content and can ensure that it complements and strengthens all aspects of undergraduate medical education.

Exploring the Cervical Cancer Screening Experiences of Black Lesbian, Bisexual, and Queer Women: The Role of Patient-Provider Communication.

Few studies have focused on the health and health care of U.S. black lesbian, bisexual, and queer (LBQ) women. To understand the facilitators of and barriers to cervical cancer screening in this population, focus group discussions were conducted in Boston and Cambridge, Massachusetts between November and December 2012. Using purposive sampling methods, the authors enrolled 18 black LBQ women who participated in one of four focus groups. Using thematic analysis, patient-provider communication was identified, which consisted of four sub-themes--health care provider communication style and demeanor; heteronormative provider assumptions; heterosexism, racism, and classism; and provider professional and sociodemographic background--as the most salient theme. Participants reported fears and experiences of multiple forms of discrimination and preferred receiving care from providers who were knowledgeable about same-sex sexual health and shared their life experiences at the intersection of gender, race/ethnicity, and sexual orientation. The cervical cancer screening experiences of black LBQ women would be improved by training all health care providers in same-sex sexual health, offering opportunities for clinicians to learn about the effects of various forms of discrimination on women's health care, and increasing the presence of LBQ women of color in health care settings.

At the intersection of sexual orientation, race/ethnicity, and cervical cancer screening: assessing Pap test use disparities by sex of sexual partners among black, Latina, and white U.S. women.

Understanding how various dimensions of social inequality shape the health of individuals and populations poses a key challenge for public health. Guided by ecosocial theory and intersectionality, we used data from the 2006-2010 National Survey of Family Growth, a national probability sample, to investigate how one dimension of sexual orientation, sex of sexual partners, and race/ethnicity jointly influence Pap test use among black, Latina and white U.S. women aged 21-44 years (N = 8840). We tested for an interaction between sex of sexual partners and race/ethnicity (p = 0.015) and estimated multivariable logistic regression models for each racial/ethnic group, adjusting for socio-demographic factors. The adjusted odds of Pap test use for women with only female sexual partners in the past year were significantly lower than for women with only male sexual partners in the past year among white women (odds ratio [OR] = 0.25, 95% confidence interval [CI]: 0.12,0.52) and may be lower among black women (OR = 0.32, 95% CI: 0.07,1.52); no difference was apparent among Latina women (OR = 1.54, 95% CI: 0.31,7.73). Further, the adjusted odds of Pap test use for women with no sexual partners in the past year were significantly lower than for women with only male sexual partners in the past year among white (OR = 0.30, 95% CI: 0.22,0.41) and black (OR = 0.23, 95% CI: 0.15,0.37) women and marginally lower among Latina women (OR = 0.63, 95% CI: 0.38,1.03). Adding health care indicators to the models completely explained Pap test use disparities for women with only female vs. only male sexual partners among white women and for women with no vs. only male sexual partners among Latina women. Ecosocial theory and intersectionality can be used in tandem to conceptually and operationally elucidate previously unanalyzed health disparities by multiple dimensions of social inequality.

Sexual orientation disparities in Papanicolaou test use among US women: the role of sexual and reproductive health services.

We investigated sexual orientation disparities in Papanicolaou screening among US women aged 21 to 44 years (n = 9581) in the 2006 to 2010 National Survey of Family Growth. The odds ratios for lesbian versus heterosexual women and women with no versus only male sexual partners were 0.40 and 0.32, respectively, and were attenuated after adjustment for sexual and reproductive health (SRH) care indicators. Administering Papanicolaou tests through mechanisms other than SRH services would promote cervical cancer screening among all women.

Abortion barriers and perceptions of gestational age among women seeking abortion care in the latter half of the second trimester.

OBJECTIVE: Later second-trimester abortion (gestational age ≥ 19 weeks) is higher risk, more expensive and more difficult to access than abortion earlier in pregnancy. We sought to enumerate barriers to care described by women seeking abortion in the latter half of the second trimester. We also assessed the accuracy of later second-trimester abortion patients' perceptions of their pregnancies' gestational ages. STUDY DESIGN: A retrospective analysis of data from 232 women served by a referral program for women seeking abortion care between 19 and 24 weeks of gestational age was performed. Data collected included demographics, pregnancy history, gestational age by ultrasound, perceived gestational age, barriers to abortion care experienced and time lapsed from pregnancy recognition to presentation for care. RESULTS: Difficulty deciding whether to terminate (44.8%), financial barriers to care (22.0%) and the patient having recently realized she was pregnant (21.6%) were the most common delaying barriers cited. Nearly half (46.6%) of women underestimated their own gestational ages by greater than 4 weeks. Risk factors for experiencing at least 3 months time lapsed from pregnancy recognition to program referral included difficulty deciding whether to terminate [odds ratio (OR) 4.08, 95% confidence interval (CI) 2.51-8.70] and nonwhite race/ethnicity (OR 2.04, 95% CI 1.16-3.57). CONCLUSIONS: Women seeking abortion care in the latter half of the second trimester encounter many of the same barriers previously identified among other abortion patient populations. Because many risk factors for delayed presentation for care are not amenable to intervention, abortion must remain available later in the second trimester. IMPLICATIONS: Women presenting for abortion in the later second trimester are delayed by structural and individual-level barriers, and many substantially underestimate their own gestational age. Removing financial barriers may help reduce abortion delay; however, many risk factors are nonmodifiable, underscoring the need to ensure access to later second-trimester abortion.

Screening for eating disorders in pregnancy: how uniform screening during a high-risk period could minimize under-recognition.

Eating disorders in the United States are on the rise, disproportionally afflict reproductive-age women, and can affect mortality rates as high as those in major depression. (1-3) Though studies have characterized associations of eating disorders with numerous adverse maternal and fetal outcomes, a paucity of studies have addressed diagnosis and management of eating disorders in pregnancy. (4-6) The present work synthesizes current literature to demonstrate how providers can improve identification by capitalizing on this high-risk period.

Impact of a health promotion intervention on maternal depressive symptoms at 15 months postpartum.

Given that diet, physical activity, and social support are associated with depression, we examined whether a health promotion intervention designed to modify these factors in low-income, postpartum women would reduce depressive symptoms. This study used a randomized, controlled design to examine the effect of the Just for You (JFY) Program, an educational intervention promoting healthy lifestyles through home visits by nutrition paraprofessionals and motivational telephone counseling, on postpartum depressive symptoms. A total of 679 women income-eligible for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) were recruited at 6-20 weeks post delivery and randomized to Usual WIC Care or JFY. Using an intention-to-treat analysis, the authors modeled depressive symptoms on the Center for Epidemiologic Studies Depression Scale (CES-D) among 403 women (59%) completing follow-up at a mean of 15 months infant age, adjusting for baseline CES-D, age, household income and randomization strata (body mass index (BMI), race/region). As a secondary analysis, the authors evaluated potential mediators related to social support and self-efficacy to change one or more health behaviors targeted by the intervention. Women randomized to JFY reported 2.5 units lower CES-D score (P = 0.046) compared with those receiving Usual WIC Care alone. This relationship was attenuated by change in self-efficacy (ß = -2.3; P = 0.065), suggesting this construct may partially have mediated the effect of JFY on maternal depressive symptoms. A health promotion intervention delivered through home visits and telephone calls can reduce depressive symptoms at 15 months postpartum among low-income, ethnically diverse women.

Social and environmental contexts of adolescent and young adult male perpetrators of intimate partner violence: a qualitative study.

The purpose of the current study was to examine qualitatively the life contexts of young males enrolled in programs addressing perpetration of intimate partner violence (IPV). Semistructured interviews were conducted with 19 males recruited from these programs. Interviews were coded to examine life contexts and analyzed using a content analysis approach. Five themes emerged across interviews: (a) disruptive home environment; (b) lack of positive male role models; (c) a peer context characterized by substance use, gang involvement, and behaviors supporting the sexual maltreatment of girls; (d) school circumstances characterized by a lack of academic support; and (e) community exposures to violence. These factors were often interrelated within the various contexts of participants. Further research is needed to provide insight into whether and how these issues may contribute to IPV perpetration. Efforts to support young males regarding a broad array of concerns should be included in programming to reduce IPV perpetration.

The role of social networks and support in postpartum women's depression: a multiethnic urban sample.

OBJECTIVES: This study examined the relationship of social support, and of social networks, to symptoms of depression in a multiethnic sample of women having recently given birth. METHODS: Women at community health centers in a Northeastern city were randomly sampled from groups stratified by race/ethnicity (African American, Hispanic, and White) and postpartum interval. Mother's score on the Center for Epidemiologic Studies of Depression Scale (CES-D) was the dependent variable. Main independent variables included the Medical Outcomes Study (MOS) Social Support Survey and a social network item. Univariate statistics assessed the relationship between CES-D score and each of the independent variables. Multivariate linear regression models included core sociodemographic variables alone, the core model with each of the social support and social network variables added separately, and all variables together. We evaluated interactions between race and social support, race and social networks, and social support and social networks. RESULTS: The multivariate models with MOS Social Support and core variables indicated that each 10-point increase in the MOS Social Support Survey was related to a 2.1-unit lower score on the CES-D (95% CI -2.4, -1.7). The inclusion of the social network variable into the core model showed that having two or more friends or family members available was associated with a 13.6-point lower mean score on the CES-D (95% CI -17.5, -9.6), compared to women reporting none or only one available person. CONCLUSIONS: Both social support and social networks were statistically significant and independently related to depressive symptomatology.