Examination of resident characteristics associated with interest in primary care and identification of barriers to cross-cultural care.

BACKGROUND: There is an increasing shortage of primary care physicians in the U.S. The difficult task of addressing patients' sociocultural needs is one reason residents do not pursue primary care. However, associations between residents' perceived barriers to cross-cultural care provision and career interest in primary care have not been investigated. OBJECTIVE: We examined residents' career interest in primary care and associations with resident characteristics and their perceived barriers in providing cross-cultural care. METHODS: We conducted a cross-sectional analysis of a resident survey from the 2018-2019 academic year. We first described residents' sociodemographic characteristics based on their career interest in primary care (Chi-square test). Our primary outcome was high career interest in primary care. We further examined associations between residents' characteristics and perceived barriers to cross-cultural care. RESULTS: The study included 155 family medicine, pediatrics, and internal medicine residents (response rate 68.2%), with 17 expressing high career interest in primary care. There were significant differences in high career interest by race/ethnicity, as Non-White race was associated with high career interest in primary care (p < 0.01). Resident characteristics associated with identifying multiple barriers to cross-cultural care included disadvantaged background, multilingualism, and foreign-born parents (all p-values< 0.05). There were no significant associations between high career interest in primary care and barriers to cross-cultural care. CONCLUSION: Residents from diverse racial/ethnic and socioeconomic backgrounds demonstrated higher career interest in primary care and perceived more barriers to cross-cultural care, underscoring the importance of increasing physician workforce diversity to address the primary care shortage and to improve cross-cultural care.

Qualitative program evaluation of social determinants of health screening and referral program.

Although the integration of social determinants of health (SDH) screening and referral programs in clinical settings has rapidly grown, the voice and experience of participants within SDH programs has not been well understood in program evaluations. To qualitatively evaluate a comprehensive SDH screening and referral program based in an academic primary care setting, we conducted a qualitative analysis of a semi-structured, focus group interview of 7 caregivers. We performed inductive coding representing emerging ideas from each transcript using focus group transcripts from families who participated in the SDH screening and referral program. A thematic model was created describing caregivers' experiences with respect to screening, intake, and referral phases of the program. Caregivers reported satisfaction with structural and process-related components of screening, intake, and referral. They expressed a preference for trained patient navigators over physicians for screening and intake for they were perceived to have time to prioritize caregivers' social needs. Caregivers reported disappointment with legal services screening, intake, and referral, citing lack of timely contact from the legal resource team and prematurity of provided legal resources. Overall, caregivers recommend the program, citing that the program provided social support, an environment where expression is encouraged, motivation to address their own health needs, and a convenient location. Overall, caregivers would recommend the program because they feel socially supported. The use of trained patient navigators appears to be instrumental to the successful implementation of the program in clinics, for navigators can provide caregivers with the appropriate time and personal attention they need to complete the survey and discuss their needs. Streamlining the referral process for evaluation of health-harming needs by the medical legal partnership was highlighted as an area for improvement.

A Faculty Development Graduate Medical Education Retreat to Teach and Address Social Determinants of Health.

BACKGROUND: Social determinants of health (SDH) account for a large percentage of health outcomes. Therefore, ensuring providers can address SDH is paramount yet curricula in this area is limited. AIM: The authors aimed to raise awareness, identify learning opportunities, foster positive attitudes, and equip educators to implement SDH curriculum. SETTING AND PARTICIPANTS: This retreat occurred at a large academic institution and had over 130 participants who represented 56 distinct training programs and over 20 disciplines. PROGRAM DESCRIPTION: The retreat was titled "Social Determinants of Health: Walking in Your Patients' Shoes." The retreat was holistic and used a multidimensional approach that included traditional learning, team-based learning, reflective practice, and prompted action. PROGRAM EVALUATION: The evaluation of this retreat included electronic surveys and both qualitative and quantitative data. The retreat's quality and effectiveness at improving participants' knowledge and skill in addressing SDH was highly rated and resulted in numerous programs, including surgical and subspecialty programs reporting adopting SDH curricular and clinical workflow changes. DISCUSSION: The retreat was successful and reached a wide and diverse set of faculty educators and can serve as an education model to the graduate medical education community on how to start to develop "physician-citizens."

The impact of United States Medical Licensing Exam (USMLE) step 1 cutoff scores on recruitment of underrepresented minorities in medicine: A retrospective cross-sectional study.

BACKGROUND AND AIMS: United States Medical Licensing Exam (USMLE) scores are the single, most objective criteria for admission into residency programs in the country. Underrepresented minorities in medicine (URiM) are found to have lower USMLE scores compared to their White counterparts. The objective of this study is to examine how USMLE step 1 cutoff scores may exclude self-reported URiM from the residency interview process across various specialties. METHODS: This was a retrospective cross-sectional study of 10 541 applicants to different residency programs at Zucker School of Medicine at Hofstra/Northwell Health between May 2014 and May 2015. We identified Blacks and Hispanics as URiM. The primary outcome is the percentage of applicants with USMLE step 1 score above different ranges of cutoff score, from 205 to 235 in five-point increments, by race/ethnicity and by URiM status. Secondary outcome is percentages of URiM vs non-URiM above and below mean USMLE step 1 scores by different specialties (internal medicine, obstetrics/gynecology, pediatrics, and psychiatry). RESULTS: The study sample included 2707 White, 722 Black, 805 Hispanic, 5006 Asian, and 562 Other Race/Ethnicity applicants. Overall, 50.2% were male, 21.3% URiM, 7.4% had limited English proficiency, 67.6% attended international medical schools, and 2.4% are Alpha Omega Alpha Honor Medical Society (AOA) members. The mean (±SD) USMLE step 1 score was significantly greater among non-URiM applicants as compared to URiM applicants (223.7 ± 19.4 vs 216.1 ± 18.4, P < .01, two-sample t-test). Non-URiM applicants were younger, and the percentage of male and AOA applicants was greater among non-URiM applicants as compared to URiM applicants (50.5% vs 47.7%, P = .02, Chi-Square test; 2.9% vs 1.2%, P < .01, Chi-Square test, respectively). CONCLUSION: Using a USMLE step 1 cutoff score as an initial filter for applicant recruitment and selection could jeopardize the benefits of a diverse residency program. Practical implications are discussed.

Defining Global Health Tracks for Pediatric Residencies.

BACKGROUND: Global health (GH) offerings by pediatric residency programs have increased significantly, with 1 in 4 programs indicating they offer a GH track. Despite growth of these programs, there is currently no widely accepted definition for what comprises a GH track in residency. METHODS: A panel of 12 pediatric GH education experts was assembled to use the Delphi method to work toward a consensus definition of a GH track and determine essential educational offerings, institutional supports, and outcomes to evaluate. The panelists completed 3 rounds of iterative surveys that were amended after each round on the basis of qualitative results. RESULTS: Each survey round had 100% panelist response. An accepted definition of a GH track was achieved during the second round of surveys. Consensus was achieved that at minimum, GH track educational offerings should include a longitudinal global child health curriculum, a GH rotation with international or domestic underserved experiences, predeparture preparation, preceptorship during GH electives, postreturn debrief, and scholarly output. Institutional supports should include resident salary support; malpractice, evacuation, and health insurance during GH electives; and a dedicated GH track director with protected time and financial and administrative support for program development and establishing partnerships. Key outcomes for evaluation of a GH track were agreed on. CONCLUSIONS: Consensus on the definition of a GH track, along with institutional supports and educational offerings, is instrumental in ensuring consistency in quality GH education among pediatric trainees. Consensus on outcomes for evaluation will help to create quality resident and program assessment tools.

Disparities in Utilization of Social Determinants of Health Referrals Among Children in Immigrant Families.

Objective: Children in immigrant families (CIF) are at elevated risk of experiencing adverse social determinants of health (SDH), particularly material hardship, which contribute to disparate health outcomes. Previous studies have found that SDH screening programs integrated into pediatric practices have increased receipt of social service resources. Few studies have examined use of social services in these programs among ethnically-diverse patient populations and associations with caregiver immigrant status or limited English proficiency (LEP). Methods: Caregivers of children (<18 years) were routinely screened in a practice-based, SDH screening program offering referral, assisted navigation and follow-up support. Information on caregiver race/ethnicity, US nativity, citizenship status and self-reported English proficiency was collected. Associations with utilization of referral resources at 12 weeks were measured using Chi-square and Fisher's Exact tests. Results: Of 148 caregivers, most were mothers (83.2%) and non-White (91.9%). Over half were born outside of the U.S (59.7%) and one-third were LEP (33.6%). Approximately one-third (30.9%) successfully utilized program-provided resources at 12-week follow-up. LEP caregivers and undocumented caregivers were more likely to be lost-to-follow-up. However, LEP caregivers who remained in the program utilized resources more than English-proficient caregivers (38.4 vs. 18.4%, p = 0.031). Similarly, significantly more non-citizen caregivers utilized referrals compared to US citizens (37.4 vs. 23.1 vs. 0.0%, p = 0.043). Conclusions: Families with non-US citizen or LEP caregivers were at highest risk of being lost-to-follow-up, but if engaged, were more likely to utilize resources. These findings indicate the need for larger studies to determine how to prevent loss-to-follow-up among immigrant and LEP caregivers participating in SDH screening programs.

The Collaborative Role of North American Departments of Pediatrics in Global Child Health.

Appeals for health equity call for departments of pediatrics to improve the health of all children including those from underserved communities in North America and around the world. Consequently, North American (NA) departments of pediatrics have a role in global child health (GCH) which focuses on providing health care to underserved children worldwide. In this review, we describe how NA departments of pediatrics can collaboratively engage in GCH education, clinical practice, research, and advocacy and summarize best practices, challenges, and next steps for engaging in GCH in each of these areas. For GCH in low- and middle-income countries (LMICs), best practices start with the establishment of ethical, equitable, and collaborative partnerships with LMIC communities, organizations, and institutions engaged in GCH who are responsible for the vast majority of work done in GCH. Other best practices include adequate preparation of trainees and clinicians for GCH experiences; alignment with local clinical and research priorities; contributions to local professional development and ongoing monitoring and evaluation. Challenges for departments include generating funding for GCH activities; recruitment and retention of GCH-focused faculty members; and challenges meeting best practices, particularly adequate preparation of trainees and clinicians and ensuring mutual benefit and reciprocity in NA-LMIC collaborations. We provide examples of how departments have overcome these challenges and suggest next steps for development of the role of NA departments of pediatrics in GCH. Collaborative implementation of best practices in GCH by LMIC-NA partnerships can contribute to reductions of child mortality and morbidity globally.

Landscape Analysis of Global Health Tracks in United States Pediatric Residencies: Moving Toward Standards.

OBJECTIVE: The number of pediatric Global Health (GH) tracks has more than doubled in less than 10 years. The goal of this study was to describe the characteristics of the pediatric GH tracks to identify commonalities and differences in track structure, funding, and education. In addition, we also identified demographic, institutional, and residency-related factors that were significantly associated with educational offerings and logistical challenges. METHODS: A cross-sectional survey was electronically administered to pediatric residency programs with GH tracks. Statistical analyses included frequencies to describe GH track characteristics. Fisher's exact tests were used to identify bivariate associations between track structure and funding with educational offerings and logistical challenges. RESULTS: Leaders of 32 pediatric GH tracks (67%) completed the survey. The majority of GH tracks were completed within the 3 years of residency (94%) and identified a GH track director (100%); however, tracks varied in size, enrollment methods, domestic and international partnerships, funding, and evaluations. Dedicated faculty time and GH track budget amounts were associated with more robust infrastructure pertaining to resident international electives, including funding and mentorship. Many tracks did not meet American Academy of Pediatrics recommended standards for clinical international rotations. CONCLUSIONS: Despite the presence of multiple similarities among pediatric GH tracks, there are large variations in track structure, education, and funding. The results from this study support the proposal of a formal definition and minimum standards for a GH track, which may provide a framework for quality, consistency, and comparison of GH tracks.

Distribution and determinants of pneumonia diagnosis using Integrated Management of Childhood Illness guidelines: a nationally representative study in Malawi.

BACKGROUND: Pneumonia remains the leading cause of child mortality in sub-Saharan Africa. The Integrated Management of Childhood Illness (IMCI) strategy was developed to standardise care in low-income and middle-income countries for major childhood illnesses and can effectively improve healthcare worker performance. Suboptimal clinical evaluation can result in missed diagnoses and excess morbidity and mortality. We estimate the sensitivity of pneumonia diagnosis and investigate its determinants among children in Malawi. METHODS: Data were obtained from the 2013-2014 Service Provision Assessment survey, a census of health facilities in Malawi that included direct observation of care and re-examination of children by trained observers. We calculated sensitivity of pneumonia diagnosis and used multilevel log-binomial regression to assess factors associated with diagnostic sensitivity. RESULTS: 3136 clinical visits for children 2-59 months old were observed at 742 health facilities. Healthcare workers completed an average of 30% (SD 13%) of IMCI guidelines in each encounter. 573 children met the IMCI criteria for pneumonia; 118 (21%) were correctly diagnosed. Advanced practice clinicians were more likely than other providers to diagnose pneumonia correctly (adjusted relative risk 2.00, 95% CI 1.21 to 3.29). Clinical quality was strongly associated with correct diagnosis: sensitivity was 23% in providers at the 75th percentile for guideline adherence compared with 14% for those at the 25th percentile. Contextual factors, facility structural readiness, and training or supervision were not associated with sensitivity. CONCLUSIONS: Care quality for Malawian children is poor, with low guideline adherence and missed diagnosis for four of five children with pneumonia. Better sensitivity is associated with provider type and higher adherence to IMCI. Existing interventions such as training and supportive supervision are associated with higher guideline adherence, but are insufficient to meaningfully improve sensitivity. Innovative and scalable quality improvement interventions are needed to strengthen health systems and reduce avoidable child mortality.

Parenting Practices and Associations with Development Delays among Young Children in Dominican Republic.

BACKGROUND: According to the World Health Organization, >200 million children in low- and middle-income countries experience developmental delays. However, household structure and parenting practices have been minimally explored as potential correlates of developmental delay in low- and middle-income countries, despite potential as areas for intervention. OBJECTIVE: The objective of the study was to examine associations of developmental delays with use of World Health Organization-recommended parenting practices among a clinic-based cohort of children aged 6-60 months attending in La Romana, Dominican Republic. METHODS: This study was conducted among 74 caregiver-child pairs attending the growth-monitoring clinic at Hospital Francisco Gonzalvo in June 2015. The Malawi Developmental Assessment Tool was adapted and performed on each child to assess socioadaptive, fine motor, gross motor, and language development. The IMCI Household Level Survey Questionnaire was used to assess parenting practices. Fisher's exact test was used to determine associations significant at P < .05. Significant variables were then entered into a multivariable logistic regression. FINDINGS: Almost two-thirds of children had a delay in at least 1 developmental domain. Most caregivers used scolding (43.2%) or spanking (44%) for child discipline. Children who were disciplined by spanking and scolding were more likely to have language delay (P = .007) and socioadaptive delay (P = .077), respectively. On regression analysis, children with younger primary caregivers had 7 times higher odds of language delay (adjusted odds ratio [AOR]: 7.35, 95% confidence interval [CI]: 1.52-35.61) and 4 times greater odds of any delay (AOR: 4.72, 95% CI: 1.01-22.22). In addition, children punished by spanking had 5 times higher odds of having language delay (AOR: 5.04, 95% CI: 1.13-22.39). CONCLUSIONS: Parenting practices such as harsh punishment and lack of positive parental reinforcement were found to have strong associations with language and socioadaptive delays. Likewise, delays were also more common among children with younger caregivers.

New views on global child health: global solutions for care of vulnerable children in the United States.

PURPOSE OF REVIEW: This paper provides a brief overview of the current landscape of global child health and the impact of social determinants on the world's children. In the United States (US), global child health (GCH) has increasingly been highlighted as a priority area by national organizations, such as the National Academy of Medicine and American Academy of Pediatrics, as well as individual pediatricians committed to ensuring the health of all children regardless of geographic location. Although GCH is commonly used to refer to the health of children outside of the US, here, we highlight the recent call for GCH to also include care of US vulnerable children. Many of the lessons learned from abroad can be applied to pediatrics domestically by addressing social determinants that contribute to health disparities. RECENT FINDINGS: Using the 'three-delay' framework, effective global health interventions target delays in seeking, accessing, and/or receiving adequate care. In resource-limited, international settings, novel health system strengthening approaches, such as peer groups, community health workers, health vouchers, cultural humility training, and provision of family-centered care, can mitigate barriers to healthcare and improve access to medical services. SUMMARY: The creative use of limited resources for pediatric care internationally may offer insight into effective strategies to address health challenges that children face here in the US. The growing number of child health providers with clinical experience in resource-limited, low-income countries can serve as an unforeseen yet formidable resource for improving pediatric care in underserved US communities.

Compliance with referrals for non-acute child health conditions: evidence from the longitudinal ASENZE study in KwaZulu Natal, South Africa.

BACKGROUND: Caregiver compliance with referrals for child health services is essential to child health outcomes. Many studies in sub-Saharan Africa have examined compliance patterns for children referred for acute, life-threatening conditions but few for children referred for non-acute conditions. The aims of this analysis were to determine the rate of referral compliance and investigate factors associated with referral compliance in KwaZulu Natal, South Africa. METHODS: From September 2008-2010, a door-to-door household survey was conducted to identify children aged 4-6 years in outer-west eThekwini District, KwaZulu-Natal, South Africa. Of 2,049 identified, informed consent was obtained for 1787 (89%) children who were then invited for baseline assessments. 1581 children received standardized medical and developmental assessments at the study facility (Phase 1). Children with anemia, suspected disorders of vision, hearing, behavior and/or development and positive HIV testing were referred to local health facilities. Caregiver-reported compliance with referrals was assessed 18-24 months later (Phase 2). Relationships between socio-demographic factors and referral compliance were evaluated using chi-square tests. RESULTS: Of 1581 children, 516 received referrals for ≥1 non-acute conditions. At the time of analysis, 68% (1078 /1581) returned for Phase 2. Analysis was limited to children assessed in Phase 2 who received a referral in Phase 1 (n = 303). Common referral reasons were suspected disorders of hearing/middle ear (22%), visual acuity (12%) and anemia (14%). Additionally, children testing positive for HIV (6.6%) were also referred. Of 303 children referred, only 45% completed referrals. Referral compliance was low for suspected disorders of vision, hearing and development. Referral compliance was significantly lower for children with younger caregivers, those living in households with low educational attainment and for those with unstable caregiving. CONCLUSIONS: Compliance with referrals for children with non-acute conditions is low within this population and appears to be influenced by caregiver age, household education level and stability of caregiving. Lack of treatment for hearing, vision and developmental problems can contribute to long-term cognitive difficulties. Further research is underway by this group to examine caregiver knowledge and attitudes about referral conditions and health system characteristics as potential determinants of referral compliance.

Comparison of high- versus low-intensity community health worker intervention to promote newborn and child health in Northern Nigeria.

BACKGROUND: In Northern Nigeria, infant mortality rates are two to three times higher than in the southern states, and, in 2008, a partnership program to improve maternal, newborn, and child health was established to reduce infant and child mortality in three Northern Nigeria states. The program intervention zones received government-supported health services plus integrated interventions at primary health care posts and development of community-based service delivery (CBSD) with a network of community volunteers and community health workers (CHWs), who focus on educating women about danger signs for themselves and their infants and promoting appropriate responses to the observation of those danger signs, consistent with the approach of the World Health Organization Integrated Management of Neonatal and Childhood Illness strategy. Before going to scale in the rest of the state, it is important to identify the relative effectiveness of the low-intensity volunteer approach versus the more intensive CBSD approach with CHWs. METHODS: We conducted stratified cluster sample household surveys at baseline (2009) and follow-up (2011) to assess changes in newborn and sick child care practices among women with births in the five prior years (baseline: n = 6,906; follow-up: n = 2,310). The follow-up respondents were grouped by level of intensity of the CHW interventions in their community, with "low" including group activities led only by a trained community volunteer and "high" including the community volunteer activities plus CBSD from a CHW providing one-on-one advice and assistance. t-tests were used to test for significant differences from baseline to follow-up, and F-statistics, which adjust for the stratified cluster design, were used to test for significant differences between the control, low-intensity, and high-intensity intervention groups at follow-up. These analyses focused on changes in newborn and sick child care practices. RESULTS: Anti-tetanus vaccination coverage during pregnancy increased from 69.2% at baseline to 85.7% at follow-up in the intervention areas. Breastfeeding within 24 hours increased from 42.9% to 59.0% in the intervention areas, and more newborns were checked by health workers within 48 hours (from 16.8% at baseline to 26.8% at follow-up in the intervention areas). Newborns were more likely to be checked by trained health personnel, and they received more comprehensive newborn care. Compared to the control communities, more than twice as many women in intervention communities knew to watch for specific newborn danger signs. Compared to the control and low-intensity intervention communities, more mothers in the high-intensity communities learned about the care of sick children from CHWs, with a corresponding decline those seeking advice from family or friends or traditional birth attendants. Significantly fewer mothers did nothing when their child was sick. High-intensity intervention communities experienced the most decline. Those who did nothing for children with fever or cough declined from 35% to 30%, and with diarrhea from 40% to 31%. Use of medications, both traditional and modern, increased from baseline to follow-up, with no differentiation in use by intervention area. CONCLUSION: The community-based approach to promoting improved newborn and sick child care through community volunteers and CHWs resulted in improved newborn and sick child care. The low-intensity approach with community volunteers appears to have been as effective as the higher-intensity CBSD approach with CHWs for several of the key newborn and sick child care indicators, particularly in the provision of appropriate home care for children with fever or cough.

Early results of an integrated maternal, newborn, and child health program, Northern Nigeria, 2009 to 2011.

BACKGROUND: This paper describes early results of an integrated maternal, newborn, and child health (MNCH) program in Northern Nigeria where child mortality rates are two to three times higher than in the southern states. The intervention model integrated critical health systems changes needed to reinvigorate MNCH health services, together with community-based activities aimed at mobilizing and enabling women to make changes in their MNCH practices. Control Local Government Areas received less-intense statewide policy changes. METHODS: The impact of the intervention was assessed using a quasi-experimental design, comparing MNCH behaviors and outcomes in the intervention and control areas, before and after implementation of the systems and community activities. Stratified random household surveys were conducted at baseline in 2009 (n = 2,129) and in 2011 at follow-up (n = 2310), with women with births in the five years prior to household surveys. Chi-square and t-tests were used to document presence of significant improvements in several MNCH outcomes. RESULTS: Between baseline and follow-up, anti-tetanus vaccination rates increased from 69.0% to 85.0%, and early breastfeeding also increased, from 42.9% to 57.5%. More newborns were checked by trained health workers (39.2% to 75.5%), and women were performing more of the critical newborn care activities at follow-up. Fewer women relied on the traditional birth attendant for health advice (48.4% to 11.0%, with corresponding increases in advice from trained health workers. At follow-up, most of these improvements were greater in the intervention than control communities. In the intervention communities, there was less use of anti-malarials for all symptoms, coupled with more use of other medications and traditional, herbal remedies. Infant and child mortality declined in both intervention and control communities, with the greatest declines in intervention communities. In the intervention communities, infant mortality rate declined from 90 at baseline to 59 at follow-up, while child mortality declined from 160 to 84. CONCLUSIONS: These results provide evidence that in the context of ongoing improvements to the primary health care system, the participatory and community-based interventions focusing on improved newborn and infant care were effective at changing infant care practices and outcomes in the intervention communities.

Determinants of influenza vaccination among young children in an inner-city community.

Few studies have examined potential factors that contribute to low influenza vaccination rates among minority children. This study aimed to assess the prevalence of early childhood influenza vaccination among young black and Latino children, living in inner-city neighborhoods, and examine the effects of child, caregiver and health system factors. Secondary data analysis was performed using a survey about medical home experiences conducted from May 2007-June 2008. The study sample was limited to children ≥6 months in any influenza season prior to the 2006-2007 influenza season. Bivariate analyses and multivariable logistic regression tested associations between influenza vaccination receipt and socio-demographic and health system characteristics. One-third of children received an influenza vaccination by the end of 2006-2007 season, while only 11% received a vaccination within their first season of eligibility. Black children were more likely than Latino children to have been vaccinated (50% vs. 31%, P<0.01) during their first few eligible seasons. Children whose mothers were older, proficient in English, and frequent users of healthcare were more likely to obtain vaccination. Child attendance at healthcare settings with immunization reminder systems was also positively correlated with influenza vaccination. Our findings suggest that initial vaccination receipt among minority children from inner-city communities might be improved by expanded influenza promotion activities targeting younger mothers or those with limited English proficiency. Strategies to increase the frequency of child's actual contact with the medical home, such as reminder systems, may be useful in improving uptake of influenza vaccination among inner-city, minority children.