Reliability and validity of diabetes nutrition self-efficacy and behavior measures for the "What Can I Eat" diabetes nutrition education program for American Indian and Alaska Native adults with type 2 diabetes.

BACKGROUND: American Indian and Alaska Native (AI/AN) people have high rates of diabetes and limited access to nutrition education. The "What Can I Eat?" (WCIE) diabetes nutrition education program was culturally adapted for AI/AN adults. OBJECTIVE: This analysis was designed to evaluate the reliability and validity of items developed to measure diabetes nutrition self-efficacy (i.e., confidence one can engage in specific behaviors) and diabetes nutrition behavior among participants in the WCIE program for AI/AN adults. DESIGN: This study was a secondary analysis of data from a randomized controlled trial designed to evaluate the WCIE program for AI/AN adults. Baseline data were used to assess the reliability and validity of the self-efficacy and behavior items, which were collected via survey. Due to COVID-19 safety protocols, the intervention was conducted via Zoom, and both survey and clinical data were collected at home by participants. PARTICIPANTS/SETTING: The study was conducted from January to December 2021 with five AI/AN-serving health care programs in Oklahoma, Illinois, North Carolina, California, and New York. AI/AN adults with type 2 diabetes who spoke English and had Internet access were eligible. Sixty participated. MAIN OUTCOME MEASURES: Analyses examined validity and reliability of diabetes nutrition self-efficacy and behavior items. STATISTICAL ANALYSIS PERFORMED: To test reliability, internal consistency and factor structures of the scales were examined. To evaluate convergent validity, Pearson correlations were computed to examine the association of the self-efficacy and behavior measures with each other and with clinical indicators (i.e., Body Mass Index, blood pressure, hemoglobin A1C). RESULTS: Two self-efficacy factors were identified. Each showed strong internal consistency (Cronbach alphas ≥ 0.85; McDonald omegas ≥ 0.88) and was directly associated with diabetes nutrition behavior (Ps < 0.001). The factor assessing Confidence in Using the Diabetes Plate was inversely associated with A1C (Pearson Correlation = -0.32, P = 0.0243). The behavior measure capturing Healthy Nutrition Behavior showed strong internal consistency (alpha = 0.89; omega = 0.92) and was inversely associated with A1C (Pearson Correlation = - 0.38, P = 0.0057). CONCLUSIONS: Diabetes nutrition self-efficacy and behavior items developed for the WCIE program for AI/AN adults are valid and reliable. These items can facilitate rigorous and consistent evaluation of the AI/AN WCIE program.

Engage, Develop, Learn: a pilot randomized clinical trial to test if a mobile application can enhance home support for early cognitive development among children living in poverty.

Background: Mobile applications (apps) exist to promote early child development; however, few studies have examined use of these apps among low-income families. Our objectives were to measure engagement with the Engage, Develop, Learn (EDL) app and determine if it promoted engagement and behavior change among low-income caregivers. Methods: We conducted a pilot study among English and Spanish-speaking, low-income families with children ages 12 to 15 months who received either the EDL app or injury prevention text messages. Baseline data were collected and interventions delivered over two home visits. App engagement was measured using messages opened. Caregiver development-promoting behaviors were measured with STIMQ score changes from baseline to follow-up at child age 2 years. We conducted key informant interviews among families randomized to receive the EDL app to identify barriers and facilitators to app use. Results: A total of 100 caregivers were recruited at their children's preventive care visit with 50 randomized to receive the EDL app and 50 to receive the injury prevention text messages; however, only 25 in the development app and 34 in the injury prevention group completed both home visits. Follow-up data were collected from 14 in the development app group and 30 in the injury prevention group. Over 10 weeks, 24% (6/25) remained engaged with the development app. STIMQ scores did not differ between groups. Barriers included technical difficulties accessing the app, social stressors, and 'forgetting' to use it. Conclusions: Our pilot randomized trial of a child development app suggests that it may not be effective for promoting behavior change among low-income caregivers due to low engagement. Trial Registration: This pilot trial was registered with ClinicalTrials.gov (ID NCT02717390).

Factors Associated With Clinician Self-Reported Resource Use in Acute Care and Ambulatory Pediatrics.

The objective of this study is to determine predictors of resource use among pediatric providers for common respiratory illnesses. We surveyed pediatric primary care, emergency department (ED)/urgent care (UC), and hospital medicine providers at a free-standing children's hospital system. Five clinical vignettes assessed factors affecting resource use for upper respiratory infections, bronchiolitis, and pneumonia, including provider-type, practice location, tolerance to uncertainty, and medical decision-making behaviors. The response rate was 75.3% (168/223). The ED/UC and primary care providers had higher vignette scores, indicating higher resource use, compared with inpatient providers; advanced practice providers (APPs) had higher vignette scores compared with physicians. In multivariate analysis, being an ED/UC provider, an APP, and greater concern for bad outcomes were associated with higher vignette scores. Overall, provider type and location of practice may predict resource use for children with respiratory illnesses. Interventions targeted at test-maximizing providers may improve quality of care and reduce resource burden.

The impact of the COVID-19 pandemic on family medicine residency training.

BACKGROUND: Family physicians have played a unique clinical role during the COVID-19 pandemic. We hypothesized that the pandemic would be associated with significant deleterious effects on clinical activity, educational training, personal safety and well-being. OBJECTIVE: We conducted a national survey to obtain preliminary data that would assist in future targeted data collection and subsequent evaluation of the impact of the pandemic on family medicine residents and teaching faculty. METHODS: An anonymous online survey of residents and faculty was distributed via the Association of Family Medicine Residency Directors list serve between 5/21/2020 and 6/18/2020. Survey questions focused on clinical and educational activities, safety and well-being. RESULTS: One hundred and fifty-three residents and 151 teaching faculty participated in the survey. Decreased clinical activity was noted by 81.5% of residents and 80.9% of faculty and the majority began conducting telehealth visits (97.9% of residents, 91.0% of faculty). Distance learning platforms were used by all residents (100%) and 39.6% noted an overall positive impact on their education. Higher levels of burnout did not significantly correlate with reassignment of clinical duties (residents P = 0.164; faculty P = 0.064). Residents who showed significantly higher burnout scores (P = 0.035) and a decline in levels of well-being (P = 0.031) were more likely to participate in institutional well-being support activities. CONCLUSIONS: Our preliminary data indicate that family medicine residents and teaching faculty were profoundly affected by the COVID-19 pandemic. Future studies can be directed by current findings with focus on mitigation factors in addressing globally disruptive events such as COVID-19.

Family physicians have played a unique clinical role during the COVID-19 pandemic. We hypothesized that the pandemic would be associated with significant deleterious effects on clinical activity, educational training, personal safety and well-being. Towards setting a foundation for further studies, we conducted a national survey to obtain preliminary data that would assist in future targeted data collection and subsequent evaluation of the impact of the pandemic on family medicine residents and teaching faculty. Our preliminary data indicate that family medicine residents and teaching faculty were profoundly affected by the COVID-19 pandemic in all domains studied. Future studies can be directed by current findings with focus on mitigation factors in addressing globally disruptive events such as COVID-19.

A Mixed Methods Evaluation of an Inclusive Sexual History Taking and HIV Prevention Curriculum for Trainees.

BACKGROUND: Health disparities exist in HIV risk in the USA among the lesbian-gay-bisexual-transgender-queer (LGBTQ) community. There is also scarce literature on curricula for HIV prevention and pre-exposure prophylaxis (PrEP) for trainees. AIM: To create a curriculum to train residents to perform inclusive sexual history taking and HIV prevention care. The curriculum covers sexual history, LGBTQ health, sexually transmitted infections, and HIV risk assessment and risk reduction counseling including use of PrEP. SETTING: A dedicated PrEP Clinic was created within an Academic Medical Center Outpatient HIV Clinic. Patients were primarily LGBTQ identified, but also included HIV sero-discordant couples, cisgender individuals, heterosexual invididuals, and those with experience of homelessness, sex work, and substance abuse. PARTICIPANTS: Thirty-four internal medicine residents completed the course between November 2017 and May 2018. PROGRAM DESCRIPTION: The curriculum was delivered as Just in Time Teaching (JiTT) via online virtual patient cases followed by directly observed clinical care at a large urban PrEP clinic. PROGRAM EVALUATION AND RESULTS: The effectiveness of the curriculum was assessed through paired pre/post-self-assessment surveys (n = 19), additional post-surveys on the online modules (n = 22), and interviews (n = 9). Many respondents reported no prior training or inadequate prior training in the course content. As a result of the course, participants reported statistically significant increased confidence and comfort in all seven HIV prevention topic areas, with the greatest gains in safe sex counseling for LGBTQ patients and in discussing PrEP (mean changes of 1.21, 1.58 on 5-point Likert scale, respectively, p < 0.0001). Six of nine interviewees post-course had applied what they learned to patient care; five indicated their learning would benefit patients. DISCUSSION: An HIV prevention curriculum focused on cultural humility in care can improve trainee's skills in HIV risk reduction counseling, including PrEP, among all patients including those identifying as LGBTQ.

Does a text-messaging program to promote early childhood development reach the highest risk families?

BACKGROUND: Bright by Three (BB3), a non-profit organization that promotes caregiver behaviors to support language development in young children was augmented with a text-messaging program, Bright by Text (BBT), in 2015. While some evidence suggests that text-messaging can promote early development, it is unknown if these interventions are reaching children at increased sociodemographic risk for developmental delay. The purpose of this study is to compare socio-demographic characteristics of caregivers who did and did not enroll in BBT. METHODS: Retrospective analysis of caregivers who received BB3 written materials and were eligible to sign up for BBT in 2016. Outcomes: (I) provision of a mobile phone number; (II) enrollment in BBT (receipt of 3+ messages). Predictors: education, marital status, race/ethnicity, insurance, language, and urban vs. rural residence. A multivariable generalized linear model was used to determine characteristics of caregivers more likely to sign up for BBT. RESULTS: A total of 18,145 caregivers received BB3 written materials; 10,843 (60%) provided a mobile phone number and 2,314 (21%) enrolled in BBT. The relative risk (RR) of enrollment was higher for caregivers who were non-minority (RR 1.15, 95% CI, 1.04-1.28), had higher education (1.60, 1.35-1.89), had private insurance (1.15, 1.15-1.28) and lived in urban areas (1.21, 1.06-1.37). Non-English speaking caregivers were less likely to enroll (0.73, 0.59-0.90). CONCLUSIONS: Caregivers with lower incomes and education, minorities and non-English speakers were less likely to enroll in BBT. Future research could identify ways to increase engagement among these populations and determine if BBT is effective in changing parent behavior and improving children's development.

Internal Medicine Residents' Perceived Responsibility for Patients at Hospital Discharge: A National Survey.

BACKGROUND: Medical residents are routinely entrusted with transitions of care, yet little is known about the duration or content of their perceived responsibility for patients they discharge from the hospital. OBJECTIVE: To examine the duration and content of internal medicine residents' perceived responsibility for patients they discharge from the hospital. The secondary objective was to determine whether specific individual experiences and characteristics correlate with perceived responsibility. DESIGN: Multi-site, cross-sectional 24-question survey delivered via email or paper-based form. PARTICIPANTS: Internal medicine residents (post-graduate years 1-3) at nine university and community-based internal medicine training programs in the United States. MAIN MEASURES: Perceived responsibility for patients after discharge as measured by a previously developed single-item tool for duration of responsibility and novel domain-specific questions assessing attitudes towards specific transition of care behaviors. KEY RESULTS: Of 817 residents surveyed, 469 responded (57.4 %). One quarter of residents (26.1 %) indicated that their responsibility for patients ended at discharge, while 19.3 % reported perceived responsibility extending beyond 2 weeks. Perceived duration of responsibility did not correlate with level of training (P = 0.57), program type (P = 0.28), career path (P = 0.12), or presence of burnout (P = 0.59). The majority of residents indicated they were responsible for six of eight transitional care tasks (85.1-99.3 % strongly agree or agree). Approximately half of residents (57 %) indicated that it was their responsibility to directly contact patients' primary care providers at discharge. and 21.6 % indicated that it was their responsibility to ensure that patients attended their follow-up appointments. CONCLUSIONS: Internal medicine residents demonstrate variability in perceived duration of responsibility for recently discharged patients. Neither the duration nor the content of residents' perceived responsibility was consistently associated with level of training, program type, career path, or burnout, suggesting there may be unmeasured factors such as professional role modeling that shape these perceptions.

A multifaceted intervention to implement guidelines did not affect hospitalization rates for nursing home-acquired pneumonia.

OBJECTIVE: Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home-acquired pneumonia (NHAP) affected hospitalization rates. DESIGN: Quasi-experimental, mixed-methods, multifaceted, unblinded intervention trial. SETTING: Sixteen nursing homes (NHs) from 1 corporation: 8 in metropolitan Denver, CO; 8 in Kansas and Missouri during 3 influenza seasons, October to April 2004 to 2007. PARTICIPANTS: Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI); NH staff and physicians were eligible. INTERVENTION: Multifaceted, including academic detailing to clinicians, within-facility nurse change agent, financial incentives, and nursing education. MEASUREMENTS: Subjects' NH medical records were reviewed for resident characteristics, disease severity, and care processes. Bivariate analysis compared hospitalization rates for subjects with stable and unstable vital signs between intervention and control NHs and time periods. Qualitative interviews were analyzed using content coding. RESULTS: Hospitalization rates for stable residents in both NH groups remained low throughout the study. Few critically ill subjects in the intervention NHs were hospitalized in either the baseline or intervention period. In control NHs, 8.7% of subjects with unstable vital signs were hospitalized during the baseline and 33% in intervention year 2, but the difference was not statistically significant (P = .10). Interviews with nursing staff and leadership confirmed there were significant pressures for, and enablers of, avoiding hospitalization for treatment of acute infections. CONCLUSIONS: Secular pressures to avoid hospitalization and the challenges of reaching NH physicians via academic detailing are likely responsible for the lack of intervention effect on hospitalization rates for critically ill NH residents.