"Living with Loss": A qualitative exploration of existential fears among people with advanced lung cancer in online lung cancer support groups.

OBJECTIVES: With targeted therapies, people are surviving longer with advanced lung cancer and engaging in online lung cancer support communities. While these groups provide a sense of community, witnessing the death of peers can lead to emotional distress. This qualitative study aims to (1) explore the experience of witnessing death in online cancer support groups; (2) identify factors that contribute to the emotional struggles of witnessing the death of peers; and (3) identify strategies/options for dealing with losses in the cancer community. METHODS: We conducted a cross-sectional analysis of qualitative interviews exploring existential concerns with participants (n = 25) from oncogene-specific online lung cancer support groups. The principal investigator conducted study interviews between August 2018 and March 2019 where participants were asked about their cancer experiences and existential concerns. We used thematic analysis and NVIVO 11 software to examine and store the de-identified interview data. RESULTS: Participants indicated that they had often witnessed their peers die and felt the pain of the loss. Factors that played a part in their struggle with witnessing others' death included the closeness of the relationship with the person, the age of the person who died, seeing oneself in the experience of the other dying, disparities in care, and losing touch in the final stages. Participants used varied coping strategies such as celebrating the life of the individual who died, engaging in advocacy efforts, not focusing on the loss, participating in therapy, and bringing self-preserving thoughts. SIGNIFICANCE OF RESULTS: Our study highlights the importance of addressing existential fears in online lung cancer support groups and incorporating conversations about death in spaces that deal with cancer.

A qualitative study of interactions with oncologists among patients with advanced lung cancer.

INTRODUCTION: To support the care of lung cancer patients, oncologists have needed to stay current on treatment advancements and build relationships with a new group of survivors in an era where lung cancer survivorship has been re-defined. The objectives of the study were to (1) understand the perspectives of advanced lung cancer patients whose tumors have oncogenic alterations about their care experiences with their oncologist(s) and (2) describe the perceptions of advanced lung cancer patients about seeking second opinions and navigating care decisions. METHODS: In this qualitative study, patients with advanced lung cancer (n = 25) on targeted therapies were interviewed to discuss their ongoing experience with their oncologists. We used deductive and inductive qualitative approaches in the coding of the data. We organized the data using the self-determination framework. RESULTS: Patients described both positive and negative aspects of their care as related to autonomy, provider competency, and connectedness. Patients sought second opinions for three primary reasons: expertise, authoritative advice, and access to clinical trial opportunities. When there is disagreement in the treatment plan between the primary oncologist and the specialist, there can be confusion and tension, and patients have to make difficult choices about their path forward. CONCLUSIONS: Patients value interactions that support their autonomy, demonstrate the competency of their providers, and foster connectedness. To ensure that patients receive quality and goal-concordant care, developing decision aids and education materials that help patients negotiate recommendations from two providers is an area that deserves further attention.

A qualitative study of online support communities for lung cancer survivors on targeted therapies.

BACKGROUND: Due to recent treatment advances, people who have non-small cell lung cancer with oncogenic alterations are an important new group of cancer survivors. Little is known about lung cancer online support communities. This research was guided by two primary questions: (1) How do these lung cancer survivors engage in online support communities? and (2) What are the psychological, social, and physical impacts of such engagement? METHODS: Qualitative in-depth interviews were conducted with patients with advanced lung cancer (N = 40) to learn about their experiences with the illness. We used qualitative thematic analysis, inductive and deductive, as outlined by Carspecken. We adapted the framework for studying online communities developed by Zhang and colleagues to examine engagement with and impacts of involvement in online lung cancer support communities. RESULTS: Participants described engaging in the online community through (1) initializing communication through asking questions or sharing resources, (2) responding to others comments or inquiries, or (3) simply observing/reading others posts. Participation had physical, psychological, or social impacts, with benefits (e.g., empowerment) and risks (e.g., feelings of jealousy or misinformation) in each domain. Participants used various strategies to mitigate negative impacts, such as distancing oneself as needed. CONCLUSIONS: Online lung cancer support communities provide support, camaraderie, and specialized health information. However, there are also risks of online engagement, such as social comparison or accessing misinformation. Understanding the utility of online support communities for lung cancer survivors on targeted therapies and further addressing their risks are urgent tasks, especially in the post-COVID era.

Telepsychiatric Consultation as a Training and Workforce Development Strategy for Rural Primary Care.

PURPOSE: There is a shortage of rural primary care personnel with expertise in team care for patients with common mental disorders. Building the workforce for this population is a national priority. We investigated the feasibility of regular systematic case reviews through telepsychiatric consultation, within collaborative care for depression, as a continuous training and workforce development strategy in rural clinics. METHODS: We developed and pilot-tested a qualitative interview guide based on a conceptual model of training and learning. We conducted individual semistructured interviews in 2018 with diverse clinical and nonclinical staff at 3 rural primary care sites in Washington state that used ongoing collaborative care and telepsychiatric consultation. Two qualitative researchers independently analyzed transcripts with iterative input from other research team members. RESULTS: A total of 17 clinical, support, and administrative staff completed interviews. Participants' feedback supported the view that telepsychiatric case review-based consultation enhanced skills of diverse clinical team members over time, even those who had not directly participated in case reviews. All interviewees identified specific ways in which the consultations improved their capacity to identify and treat psychiatric disorders. Perceived benefits in implementation and sustainability included fidelity of the care process, team resilience despite member turnover, and enhanced capacity to use quality improvement methods. CONCLUSIONS: Weekly systematic case reviews using telepsychiatric consultation served both as a model for patient care and as a training and workforce development strategy in rural primary care sites delivering collaborative care. These are important benefits to consider in implementing the collaborative care model of behavioral health integration.

Explicating practice norms and tensions between values in resident training in family medicine.

BACKGROUND: Residency programs have the intricate and complex role of training health care providers. But little is known about what residents and attendings consider norms of practice or the tensions among different values residents are expected to uphold. Thus, dialogical and reflective frameworks are being explored for resident learning. METHODS: This study examined the use of facilitated conversations with groups of residents and attending physicians while reviewing video-recorded resident-patient interactions. The conversations were recorded, transcribed, and qualitatively analyzed. RESULTS: A total of 24 residents and 10 attendings participated in conversations while separately and in parallel groups reviewing 15 resident sessions. Residents explicated the norms of practice and evaluated their performance, which often agreed with those of attending physicians in calling out important learning opportunities. When disagreement occurred, residents' explications of their reasoning were often relevant and, via reflection and dialogue, helped clarify intentions that were not apparent in the videos. Residents and attendings often judged actions on more than one domain of value. For instance, if a resident addressed problems, built relationships in a timely manner, and acted autonomously without jeopardizing the quality of care, she satisfactorily performed her duty. CONCLUSIONS: Practice norms and value struggles were addressed by participants during reviews, which provided a promising framework for learning and assessment. Also, the non-hierarchical structure opened space to acknowledge a diversity of positions and for tensions among values to be explicated.

The effects of state rules on opioid prescribing in Indiana.

BACKGROUND: Prescription opioids have been linked to over half of the 28,000 opioid overdose deaths in 2014. High rates of prescription opioid non-medical use have continued despite nearly all states implementing large-scale prescription drug monitoring programs (PDMP), which points to the need to examine the impact of state PDMP's on curbing inappropriate opioid prescribing. In the short-term, PDMPs have been associated with short-term prescribing declines. Yet little is known about how such policies differentially impact patient subgroups or are interpreted by prescribing providers. Our objective was to compare volumes of prescribed opioids before and after Indiana implemented opioid prescribing emergency rules and stratify the changes in opioid prescribing by patient and provider subgroups. METHODS: An interrupted time series analysis was conducted using data obtained from the Indiana PDMP. Prescription level data was merged with census data to characterize patient socioeconomic status. Analyses were stratified by patients' gender, age, opioid dosage, and payer. The primary outcome indicator was the total morphine equivalent dose (MED) of dispensed opioids per day in the state of Indiana. Also considered were number of unique patients, unique providers, and prescriptions; MED per transaction and per day; and number of days supplied. RESULTS: After controlling for time trends, we found that total MED for opioids decreased after implementing the new emergency rules, differing by patient gender, age, and payer. The effect was larger for males than females and almost 10 times larger for 0-20 year olds as compared to the 60+ age range. Medicare and Medicaid patients experienced more decline in prescribing than patients with private insurance. Patients with prescriptions paid for by workers' comp experienced the most significant decline. The emergency rules were associated with decline in both the number of prescribers and the number of day supply. CONCLUSIONS: Although the Indiana opioid prescribing emergency rules impacted statewide prescribing behavior across all individual patient and provider characteristics, the emergency rules' effect was not consistent across patient characteristics. Further studies are needed to assess how individual patient characteristics influence the interpretation and application of state policies on opioid prescribing.

Interprofessional education in graduate medical education: survey study of residency program directors.

BACKGROUND: The overarching purpose of this study is to examine the current trends in interprofessional education (IPE) within graduate medical education in the Unites States. METHODS: A survey was sent to program directors across with different specialties between March and April 2016. The survey was completed by 233 out of 1757 program directors, which represents a response rate of 13.3%. RESULTS: IPE is currently being used by over 60% of the GME program directors that completed the survey. The median number of IPE hours is 60. Classroom learning (70.8%) and team-based approaches (70.1%) to patient care are the two most common forms of IPE. The two most prevalent reasons for implementing IPE are improving collaboration (92.2%) and communication (87%). More than half of the program directors agreed or strongly agreed that lack of time both for teachers (54.4) and for residents (51.5%) are barriers to IPE. About one third of the respondents whose programs do not include IPE are interested in implementing some IPE in the future. CONCLUSION: IPE in its varying formats has been implemented as a training model by many residency programs. Further studies are needed to explore the comparative effectiveness of the different modalities of IPE.

Billing by residents and attending physicians in family medicine: the effects of the provider, patient, and visit factors.

BACKGROUND: Medical billing and coding are critical components of residency programs since they determine the revenues and vitality of residencies. It has been suggested that residents are less likely to bill higher evaluation and management (E/M) codes compared with attending physicians. The purpose of this study is to assess the variation in billing patterns between residents and attending physicians, considering provider, patient, and visit characteristics. METHOD: A retrospective cohort study of all established outpatient visits at a family medicine residency clinic over a 5-year period was performed. We employed the logistic regression methodology to identify residents' and attending physicians' variations in coding E/M service levels. We also employed Poisson regression to test the sensitivity of our result. RESULTS: Between January 5, 2009 and September 25, 2015, 98,601 visits to 116 residents and 18 attending physicians were reviewed. After adjusting for provider, patient, and visit characteristics, residents billed higher E/M codes less often compared with attending physicians for comparable visits. In comparison with attending physicians, the odds ratios for billing higher E/M codes were 0.58 (p = 0.01), 0.56 (p = 0.01), and 0.63 (p = 0.01) for the third, second, and first years of postgraduate training, respectively. In addition to the main factors of patient age, medical conditions, and number of addressed problems, the gender of the provider was also implicated in the billing variations. CONCLUSION: Residents are less likely to bill higher E/M codes than attending physicians are for similar visits. While these variations are known to contribute to lost revenues, further studies are required to explore their effect on patient care in relation to attendings' direct involvement in higher E/M-coded versus their indirect involvement in lower E/M-coded visits.

Never Felt at Home: A Qualitative Study of the Experiences of Faculty From Underrepresented Groups in Family Medicine and Strategies for Empowerment.

BACKGROUND AND OBJECTIVES: Increasing diversity among medical educators is a vital step toward diversifying the physician workforce. This study examined how gender, race, and other attributes affect family medicine department chairs' experiences with sponsoring, mentoring, and coaching (SMC). We identified strategies at multiple levels to enhance SMC for faculty from underrepresented groups (URGs). METHODS: Our qualitative study employed semistructured interviews with the chairs of departments of family medicine in the United States. We used inductive and deductive thematic analysis approaches to describe the experience and name usable strategies organized along the social-ecological model. RESULTS: We interviewed 20 family medicine department chairs between December 2020 and May 2021. Many participants continued to be alarmed that leaders and role models from URGs have been rare. Participants described incidents of aggression in White- and male-dominated atmospheres. Such experiences left some feeling not at home. Some White male leaders appeared oblivious to the experiences of URG faculty, many of whom were burdened with a minority tax. For some URGs, surviving meant moving to a more supportive institution. Building spaces for resiliency and connecting with others to combat discrimination gave meaning to some participants. Participant responses helped identify multilevel strategies for empowerment and support for URG faculty. CONCLUSIONS: Understanding the experiences of URG faculty is paramount to improving the environment in academic medicine-paving the way to enhancing diversity in the health care sector. Institutions and individuals need to develop multilevel strategies for empowerment and support to actively make diverse faculty feel at home.

How to Sponsor, Coach, and Mentor: A Qualitative Study With Family Medicine Department Chairs.

BACKGROUND AND OBJECTIVES: The goal of this study was to explore how to use sponsoring, coaching, and mentoring (SCM) for faculty development by clarifying the functions embedded in SCM. The study aims to ensure that department chairs can be intentional in providing those functions and/or playing those roles for the benefit of all their faculty. METHODS: We used qualitative, semistructured interviews in this study. We followed a purposeful sampling strategy to recruit a diverse sample of family medicine department chairs across the United States. Participants were asked about their experiences receiving and providing sponsoring, coaching, and mentoring. We iteratively coded audio recorded and transcribed interviews for content and themes. RESULTS: We interviewed 20 participants between December 2020 and May 2021 to identify actions associated with sponsoring, coaching, and mentoring. Participants identified six main actions sponsors perform. These actions are identifying opportunities, recognizing an individual's strengths, encouraging opportunity-seeking, offering tangible support, optimizing candidacy, nominating as a candidate, and promising support. In contrast, they identified seven main actions a coach performs. These are clarifying, advising, giving resources, performing critical appraisals, giving feedback, reflecting, and scaffolding (ie, providing support while learning). Finally, participants identified six main actions the mentors perform. The list includes checking in, listening, sharing wisdom, directing, supporting, and collaborating. CONCLUSIONS: We present SCM as an identifiable series of actions that need to be thought of and performed intentionally. Our clarification will help leaders purposefully select their actions and allows opportunity for evaluating their effectiveness. Future research will explore developing and evaluating programs that support learning how to provide SCM in order to enhance the process of faculty development and provide it equitably.

Integrating Immigrant Health Professionals into the U.S. Healthcare Workforce: Barriers and Solutions.

Internationally educated immigrant healthcare workers face skill underutilization working in lower-skilled healthcare jobs or outside healthcare. This study explored barriers to and solutions for integrating immigrant health professionals. Content analysis identifying key themes from semi-structured qualitative interviews with representatives from Welcome Back Centers (WBCs) and partner organizations. 18 participants completed interviews. Barriers facing immigrant health professionals included lack of access to resources, financial constraints, language difficulties, credentialing challenges, prejudice, and investment in current occupations. Barriers facing programs that assist immigrant health professionals included eligibility restrictions, funding challenges, program workforce instability, recruitment difficulties, difficulty maintaining connection, and pandemic challenges. Long-term program success depended on partner networks, advocacy, addressing prejudice, a client-centered approach, diverse resources and services, and conducting research. Initiatives to integrate immigrant health professionals require multi-level responses to diverse needs and collaborations among organizations that support immigrant health professionals, healthcare systems, labor, and other stakeholders.

Factors leading to disparity in lung cancer diagnosis among black/African American communities in the USA: a qualitative study.

OBJECTIVE: This study has two objectives: first, to explore the diagnostic experiences of black/African American (BAA) patients with lung cancer to pinpoint pitfalls, suboptimal experiences and instances of discrimination leading to disparities in outcomes compared with patients of other ethnic backgrounds, especially white patients. The second objective is to identify the underlying causes contributing to health disparities in the diagnosis of lung cancer among BAA patients. METHODS: We employed a phenomenological research approach, guiding in-depth interviews with patients self-identifying as BAA diagnosed with lung cancer, as well as caregivers, healthcare professionals and community advocates knowledgeable about BAA experiences with lung cancer. We performed thematic analysis to identify experiences at patient, primary care and specialist levels. Contributing factors were identified using the National Institute of Minority Health and Health Disparities (NIMHD) health disparity model. RESULTS: From March to November 2021, we conducted individual interviews with 19 participants, including 9 patients/caregivers and 10 providers/advocates. Participants reported recurring and increased pain before seeking treatment, treatment for non-cancer illnesses, delays in diagnostic tests and referrals, poor communication and bias when dealing with specialists and primary care providers. Factors contributing to suboptimal experiences included reluctance by insurers to cover costs, provider unwillingness to conduct comprehensive testing, provider bias in recommending treatment, high healthcare costs, and lack of healthcare facilities and qualified staff to provide necessary support. However, some participants reported positive experiences due to their insurance, availability of services and having an empowered support structure. CONCLUSIONS: BAA patients and caregivers encountered suboptimal experiences during their care. The NIMHD model is a useful framework to organise factors contributing to these experiences that may be leading to health disparities. Additional research is needed to fully capture the extent of these experiences and identify ways to improve BAA patient experiences in the lung cancer diagnosis pathway.

Patient-led advocacy in ALK-positive lung cancer.

Patient-led advocacy organizations in the anaplastic lymphoma kinase (ALK)-positive lung cancer space are becoming increasingly influential. ALK Positive Inc. (hereafter "ALK Positive") is probably the most widely known among these organizations. Evolving from a private Facebook Support Group created in 2015 to provide a forum for ALK-positive lung cancer patients and caregivers to exchange information, empathy and support, ALK Positive transitioned in 2021 into a 501(c)(3) non-profit organization (NPO), with the mission to improve the life expectancy and quality of life for ALK-positive cancer patients worldwide. This review provides a historical perspective on the growth, activities and aspirations of ALK Positive to pursue patient advocacy and enable development of new therapies for individuals with ALK-positive cancers. This growth has been enabled by the collaborative efforts of ALK-positive cancer patients, their care-partners and oncologists, academic researchers, other NPO advocacy organizations, and members of the biotech and pharma communities who develop new therapies for ALK-positive cancers. ALK Positive has grown to provide a variety of patient services, to award competitive support for translational research and clinical trials intended to enable new therapies and improved quality and extent of life for ALK-positive cancer patients, and to collaborate with industry and academia to accelerate the development of improved therapies for ALK-positive cancer patients. ALK Positive continues grappling with a variety of challenges including further improving patient quality of life, enabling the development of new therapies, and extending its already substantial global reach and impact. This review summarizes many of the tangible impacts and aspirations engendered by ALK Positive for ALK-positive cancer patients in the past, present and future tenses-where we have been, where we stand and where we hope to go. The content is based on the historical recollections of the authors, and is accurate as of November 30, 2022, to the best of the authors' knowledge.

Previous Health Care Experiences' Influence on Health Care Perceptions Among Residents of Six Homeless Shelters in Seattle, Washington, July-October 2021.

Purpose: The study purpose was to learn and describe 1) where homeless shelter residents receive health care, 2) what contributes to positive or negative health care experiences among shelter residents, and 3) shelter resident perceptions toward health care. Methods: Semi-structured interviews (SSIs) utilizing purposive sampling and focus group discussions (FGDs) utilizing convenience sampling were conducted at 6 homeless shelters in Seattle-King County, Washington, during July-October 2021. All residents (age ≥18) were eligible to participate. SSIs were conducted with 25 residents, and 8 FGDs were held. Thematic analysis was conducted using Dedoose. Results: Participants received health care in settings ranging from no regular care to primary care providers. Four elements emerged as contributing positively and negatively to health care experiences: 1) ability to access health care financially, physically, and technologically; 2) clarity of communication from providers and staff about appointment logistics, diagnoses, and treatment options; 3) ease of securing timely follow-up services; and 4) respect versus stigma and discrimination from providers and staff. Participants who felt positively toward health care found low- or no-cost care to be widely available and encouraged others to seek care. However, some participants described health care in the United States as greedy, classist, discriminatory, and untrustworthy. Participants reported delaying care and self-medicating in anticipation of discrimination. Conclusions: Findings demonstrate that while people experiencing homelessness can have positive experiences with health care, many have faced negative interactions with health systems. Improving the patient experience for those experiencing homelessness can increase engagement and improve health outcomes.

Symptoms and signs of lung cancer prior to diagnosis: case-control study using electronic health records from ambulatory care within a large US-based tertiary care centre.

OBJECTIVE: Lung cancer is the most common cause of cancer-related death in the USA. While most patients are diagnosed following symptomatic presentation, no studies have compared symptoms and physical examination signs at or prior to diagnosis from electronic health records (EHRs) in the USA. We aimed to identify symptoms and signs in patients prior to diagnosis in EHR data. DESIGN: Case-control study. SETTING: Ambulatory care clinics at a large tertiary care academic health centre in the USA. PARTICIPANTS, OUTCOMES: We studied 698 primary lung cancer cases in adults diagnosed between 1 January 2012 and 31 December 2019, and 6841 controls matched by age, sex, smoking status and type of clinic. Coded and free-text data from the EHR were extracted from 2 years prior to diagnosis date for cases and index date for controls. Univariate and multivariable conditional logistic regression were used to identify symptoms and signs associated with lung cancer at time of diagnosis, and 1, 3, 6 and 12 months before the diagnosis/index dates. RESULTS: Eleven symptoms and signs recorded during the study period were associated with a significantly higher chance of being a lung cancer case in multivariable analyses. Of these, seven were significantly associated with lung cancer 6 months prior to diagnosis: haemoptysis (OR 3.2, 95% CI 1.9 to 5.3), cough (OR 3.1, 95% CI 2.4 to 4.0), chest crackles or wheeze (OR 3.1, 95% CI 2.3 to 4.1), bone pain (OR 2.7, 95% CI 2.1 to 3.6), back pain (OR 2.5, 95% CI 1.9 to 3.2), weight loss (OR 2.1, 95% CI 1.5 to 2.8) and fatigue (OR 1.6, 95% CI 1.3 to 2.1). CONCLUSIONS: Patients diagnosed with lung cancer appear to have symptoms and signs recorded in the EHR that distinguish them from similar matched patients in ambulatory care, often 6 months or more before diagnosis. These findings suggest opportunities to improve the diagnostic process for lung cancer.

The AYA Care Plan: Initial Evaluation of a Web-Based Psychosocial Intervention.

PURPOSE: Adolescents and young adults (AYA) with cancer do not fit neatly into pediatric or older adult oncology care settings. Recent efforts have led to the development of psychosocial interventions for AYAs, but studies show AYAs demonstrate low levels of engagement in psychosocial services. The AYA Care Plan is one of the only web-based tools providing a personalized, psychosocial resource that addresses unmet needs for AYAs in active treatment and post-treatment survivorship. The current study aims to assess the usability and utility of the AYA Care Plan and identify opportunities for improvement. METHODS: Clinic staff administered an online distress and needs assessment to AYA patients with cancer at outpatient oncology clinics. Personalized care plans were sent to participants on the basis of their responses. A total of 11 AYAs between the ages 18 and 39 years, with a mean age of 31.64 years, then completed qualitative interviews about their experiences. Thematic analysis was used to identify themes on the AYA Care Plan. RESULTS: A majority of participants reported positive usability features. Half of the participants reported using their care plan to make health care decisions. One person indicated not finding the resources helpful, and the other half of participants reported not engaging with the care plan. Participants also offered suggestions for improvement. CONCLUSION: The AYA Care Plan appears to be a useful psychosocial intervention for some AYAs with cancer. Future research should continue to examine the AYA Care Plan's usability and utility, and specify when, how, and for whom the AYA Care Plan is useful.

Trends and factors associated with change in COVID-19 vaccination intent among residents and staff in six Seattle homeless shelters, March 2020 to August 2021.

Introduction: Achieving high COVID-19 vaccination coverage in homeless shelters is critical in preventing morbidity, mortality, and outbreaks, however, vaccination coverage remains lower among people experiencing homelessness (PEH) than the general population. Methods: We conducted a cross-sectional study to retrospectively describe attitudes and identify factors associated with change in COVID-19 vaccination intent among shelter residents and staff during March 2020 - August 2021. To identify factors associated with change in COVID-19 vaccine intent becoming more positive overall compared to other attitudes, we utilized a Poisson model to calculate Risk Ratios with robust standard errors, adjusting for confounding by shelter site and demographic variables determined a priori. Results: From July 12 - August 2, 2021, 97 residents and 20 staff participated in surveys across six shelters in Seattle King County, Washington. Intent to be vaccinated against COVID-19 increased from 45.3 % (n = 53) when recalling attitudes in March 2020 to 74.4 % (n = 87) as of August 2021, and was similar among residents and staff. Many participants (43.6 %, n = 51) indicated feeling increasingly accepting about receiving a COVID-19 vaccine since March 2020, while 13.7 % (n = 16) changed back and forth, 10.3 % (n = 12) became more hesitant, and 32.5 % (n = 38) had no change in intent. In the model examining the relationship between becoming more positive about receiving a COVID-19 vaccine compared to all other attitudes (n = 116), we found a 57.2 % increase in vaccine acceptability (RR 1.57; 95 % CI: 1.01, 2.45) among those who reported worsening mental health since the start of the pandemic. Conclusions: Findings highlight opportunities to improve communication with residents and staff about COVID-19 vaccination and support a need for continued dialogue and a person-centered approach to understanding the sociocultural complexities and dynamism of vaccine attitudes at shelters.Clinical Trial Registry Number: NCT04141917.

Appraising and Handling COVID-19 Information: A Qualitative Study.

BACKGROUND: The coronavirus pandemic brought vast quantities of new information to the public for rapid consumption. This study explored how people most impacted by the pandemic have judged and perceived the quality of information regarding COVID-19 and regulated the information flow. METHODS: This was a qualitative study of semi-structured interviews developed as a pragmatic study targeting several groups most impacted by the pandemic. Participants were identified through convenience, purposive, and snowball sampling methods. They were interviewed by phone or video conference. RESULTS: Twenty-five participants were interviewed between 6 April 2020 and 1 May 2020. In terms of verifying information and judging its quality, people judged information by the source. People compared information across sources and attempted to verify the quality. Most felt self-assured about their capacity to judge information. Regarding the quality of information, many participants felt the information was skewed or inaccurate. Contradictory information was confusing, especially with a strong suspicion of ulterior motives of information sources impacting trust in the provided information. Yet, some recognized the iterative process of healthcare-related information. In terms of regulating information flow, many participants perceived flooding with information. To counter information overload, some became selective with types of information input. Many developed the habit of taking breaks periodically. CONCLUSION: Improving risk communication in a pandemic is of paramount importance. Organizations working in public health must develop ways to regulate information flow in collaboration with trusted community partners. Individuals also must develop strategies to improve information management.

Family Medicine Resident Knowledge of Adverse Childhood Experiences.

INTRODUCTION: Exposure to adverse childhood experiences (ACEs) has been associated with poor health in adulthood. Primary care providers can provide more appropriate medical care and intervene if they ask patients about ACEs. The purpose of this study is to determine existing knowledge and attitudes about ACEs among family medicine residents within the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region. METHODS: Researchers developed a nine-question survey to assess family medicine residents' knowledge and attitudes about ACEs, and their comfort level in addressing ACEs. The survey was distributed to 540 residents in 22 family medicine residency programs in the WWAMI region. RESULTS: Most residents reported they had some (32%) or moderate (35%) knowledge of the ACEs study. However, 30% reported no knowledge of the ACEs study, and very few (3%) reported significant knowledge. Of 117 respondents reporting at least some prior knowledge of ACEs, 42% had first heard about ACEs during residency. The ACEs topics that respondents felt least comfortable addressing during a patient encounter were a patient's personal history of sexual abuse (75%) and witnessing physical abuse (47%). Most residents (84%) indicated that they would like to see ACEs integrated into their residency curriculum. DISCUSSION: This study demonstrates a gap in residency training on the topic of ACEs in family medicine residencies within the WWAMI region. Residents are uncomfortable addressing ACEs with patients but are receptive to learning about this topic. More teaching about ACEs can increase residents' comfort level with addressing these topics in the primary care setting.