First Responders During COVID-19: Career Calling, PTSD, and Work Self-Efficacy.

INTRODUCTION: During the COVID-19 pandemic, first responders were identified as a high-risk group for developing symptoms of post-traumatic stress disorder (PTSD) and depression, which are commonly associated with negative thoughts about oneself. This may pose risk to perceptions of work self-efficacy, an integral component of employee well-being and occupational functioning. In line with the Job Demands-Resources Model (Demerouti et al., 2001), the present study examined whether the degree to which first responders' perceived career calling (i.e., a "summons" to work) served as a protective factor in the relationship between PTSD symptoms associated with the COVID-19 pandemic and perceptions of self-efficacy in the workplace. METHODS: Participants were 138 first responders from local county police and fire departments who completed online screening measures for probable PTSD and depression, as well as self-reports of work self-efficacy and career calling, between May and June 2020. Statistical analysis occurred between 2020 and 2021. RESULTS: Moderation analysis, controlling for depression and relevant covariates, revealed an interaction between PTSD symptoms and career calling, ΔR2=0.04, p=0.017. At low levels of career calling, there was a significant and negative relationship between PTSD symptoms and work self-efficacy (b=‒0.14, p=0.023), but not among first responders with average or high calling (p's>0.58). Positive screening rates were 22% for probable PTSD and 19% for depression. CONCLUSIONS: Perceiving a career calling may help protect first responders during COVID-19 from the deleterious effects of PTSD symptomatology on work self-efficacy. Prevention efforts targeting first responders with low calling strength may be warranted.

More Than Half of Family Medicine Clerkships Do Not Address Systemic Racism: A CERA Study.

BACKGROUND AND OBJECTIVES: The influence of racism in medicine is increasingly acknowledged, and the negative effect of systemic racism on individual and population health is well established. Yet, little is known about how or whether medical students are being educated on this topic. This study investigated the presence and features of curricula related to systemic racism in North American family medicine clerkships. METHODS: We conducted a survey of North American family medicine clerkship directors as part of the 2021 Council of Academic Family Medicine's Educational Research Alliance (CERA) survey. RESULTS: The survey response rate was 49% (78/160). Almost all clerkship directors agreed (n=68; 97.1%) that teaching about racism at all levels of medical education was appropriate. Yet, 60% (n=42) of family medicine clerkship directors reported no formalized curriculum for teaching about racism or bias. Teaching about systemic racism was more likely to be present in the family medicine clerkship at institutions where clerkship directors reported that faculty receive 5 or more hours of training in racism and bias, as compared to institutions where faculty receive 4 or fewer hours of training in racism/bias (odds ratio 2.82, 95% CI 1.05-8.04, P=.045). Programs reported using racism in medicine curricula based in cultural competency (20%); structural competency (10%); both cultural and structural competency (31%); and neither or uncertain (40%). Clerkship directors reported high faculty, student, and institutional engagement in addressing systemic racism. We did not find an association between underrepresented in medicine director identity and racism curricula. CONCLUSIONS: In more than half of family medicine clerkships, systemic racism is not addressed, despite interest from students and institutional support. A higher number of hours of faculty training time on the topic of racism was associated with having a systemic racism module in the clerkship curriculum, but we lacked data to identify a causal relationship. Investments in faculty development to teach systemic racism, including discussion of structural competency, are needed.

Implementation intentions and colorectal screening: a randomized trial in safety-net clinics.

CONTEXT: Low-income and racial/ethnic minority populations experience disproportionate colorectal cancer (CRC) burden and poorer survival. Novel behavioral strategies are needed to improve screening rates in these groups. BACKGROUND: The study aimed to test a theoretically based "implementation intentions" intervention for improving CRC screening among unscreened adults in urban safety-net clinics. DESIGN: Randomized controlled trial. SETTING/PARTICIPANTS: Adults (N=470) aged ≥50 years, due for CRC screening, from urban safety-net clinics were recruited. INTERVENTION: The intervention (conducted in 2009-2011) was delivered via touchscreen computers that tailored informational messages to decisional stage and screening barriers. The computer then randomized participants to generic health information on diet and exercise (Comparison group) or "implementation intentions" questions and planning (Experimental group) specific to the CRC screening test chosen (fecal immunochemical test or colonoscopy). MAIN OUTCOME MEASURES: The primary study outcome was completion of CRC screening at 26 weeks based on test reports (analysis conducted in 2012-2013). RESULTS: The study population had a mean age of 57 years and was 42% non-Hispanic African American, 28% non-Hispanic white, and 27% Hispanic. Those receiving the implementation intentions-based intervention had higher odds (AOR=1.83, 95% CI=1.23, 2.73) of completing CRC screening than the Comparison group. Those with higher self-efficacy for screening (AOR=1.57, 95% CI=1.03, 2.39), history of asthma (AOR=2.20, 95% CI=1.26, 3.84), no history of diabetes (AOR=1.86, 95% CI=1.21, 2.86), and reporting they had never heard that "cutting on cancer" makes it spread (AOR=1.78, 95% CI=1.16, 2.72) were more likely to complete CRC screening. CONCLUSIONS: The results of this study suggest that programs incorporating an implementation intentions approach can contribute to successful completion of CRC screening even among very low-income and diverse primary care populations. Future initiatives to reduce CRC incidence and mortality disparities may be able to employ implementation intentions in large-scale efforts to encourage screening and prevention behaviors.

Colorectal cancer screening, perceived discrimination, and low-income and trust in doctors: a survey of minority patients.

BACKGROUND: Completion of colorectal cancer (CRC) screening testing is lower among low-income and minority groups than the population as a whole. Given the multiple cancer screening health disparities known to exist within the U.S., this study investigated the relationship between perceived discrimination, trust in most doctors, and completion of Fecal Occult Blood Testing (FOBT) among a low-income, minority primary care population in an urban setting. METHODS: We recruited a convenience sample of adults over age 40 (n = 282) from a federally qualified community health center (70% African American). Participants completed a survey which included measures of trust in most doctors, perceived discrimination, demographics and report of cancer screening. RESULTS: Participants reported high levels of trust in most doctors, regardless of sex, race, education or income. High trust was associated with low perceived discrimination (p < 0.01). The trend was for older participants to express more trust (p = 0.09) and less perceived discrimination (p < 0.01). Neither trust nor discrimination was associated with race or education. Trust was higher among participants over 50 who were up-to-date on FOBT screening vs. those who were not (31 vs. 29 (median), p < 0.05 by T-test). Among those over 50, up-to-date FOBT screening was nearly associated with high trust (p < 0.06; 95% CI 0.99, 1.28) and low perceived discrimination (p < 0.01; 95% CI 0.76, 0.96). Nevertheless, in multivariate-modeling, age and income explained FOBT completion better than race, trust and discrimination. CONCLUSION: Perceived discrimination was related to income, but not race, suggesting that discrimination is not unique to minorities, but common to those in poverty. Since trust in most doctors trended toward being related to age, FOBT screening could be negatively influenced by low trust and perceived discrimination in health care settings. A failure to address these issues in middle-aged, low income individuals could exacerbate future disparities in CRC screening.

The impact of socioeconomic status on perceived barriers to colorectal cancer testing.

PURPOSE: Colorectal cancer (CRC) screening is effective, but only one-half of age-eligible adults adhere to national guidelines. Lower socioeconomic status (SES) groups are less likely to be screened. METHODS: Baseline data from a prospective study were, used to examine the associations among CRC screening screening barriers, and SES. A convenience sample of adults (N = 291) aged 40 years and older was recruited from a federally qualified health center. Questionnaires were administered orally and included demographics, health, health behavior, and screening barriers. RESULTS: In logistic regression, having health insurance was associated with greater odds of screening Bivariate analyses detected few differences in fecal occult blood test (FOBT) barriers, but several endoscopy barriers were more common among the lowest SES groups. For example, fear of injury from endoscopy was more likely among low-income and uninsured participants. DISCUSSION: The impact of SES on cancer screening is complex, but low-SES participants more often reported certain barriers than their higher-SES counterparts. This was more evident for endoscopy than for FOBT. Programs targeted at low-SES patients may need to focus on barriers that are not fully addressed in traditional promotion efforts.

Comparison of body perceptions between obese primary care patients and physicians: implications for practice.

OBJECTIVE: To compare the body image and weight perceptions of primary care patients and their physicians as a first step toward identifying a potential tool to aid physician-patient communication. METHODS: Patients with a body mass index (BMI)> or =30 (n=456, 66% female) completed body image and weight status measures after office visits; physicians (n=29) rated the body figures and weight status of these same patients after office visits. RESULTS: Controlling for BMI, female patients and their physicians showed little or no difference in body figure selection or weight status classification, whereas male patients were significantly less likely than their physicians to self-identify with larger body figures (z=3.74, p<0.01) and to classify themselves as obese or very obese (z=4.83, p<0.0001). CONCLUSION: Findings reveal that physicians and female patients have generally concordant views of the patient's body size and weight status, whereas male patients perceive themselves to be smaller than do their physicians. The discrepancy between male patient and physician views is especially evident at increasingly larger body figure/weight status categories. PRACTICE IMPLICATIONS: When counseling male patients on weight loss, it could be helpful to assess body image and use this information to raise patient awareness of their size and to facilitate communication about weight.

Discussing weight with obese primary care patients: physician and patient perceptions.

OBJECTIVE: To evaluate patient-provider agreement on whether weight and related behaviors were discussed during routine visits. DESIGN: Post-visit survey assessments of patients and providers. PARTICIPANTS: Obese patients make up the majority of all patients seen in primary care (PC). The patients and physicians were recruited at the time of PC visits. MEASUREMENTS AND MAIN RESULTS: Percent patient-physician agreement and patient, provider and practice characteristics associated with agreement. Patients (456) and physicians (30) agreed about whether or not they discussed weight, physical activity (PA), and diet for 61% of office visits. There was disagreement on one of the items (weight, PA, or diet) for 23% of office visits, and for 2 or more of the items for 16% of the visits. Agreement was relatively greater for discussing weight than for discussing diet or physical activity. Physicians reported discussing weight issues more often than did patients. Overall patient-physician agreement was 0.51-0.59 (weighted Kappa statistic). In a multivariate analyses of factors associated with patient-physician agreement, health insurance (odds ratio [OR]=3.67, p value = 0.002), physician description of patient weight status (OR = 2.27, p value = 0.002), patient report of how weight relates to health (OR = 1.70, p value = 0.04), and female patient gender (OR = 1.62, p = value = 0.02) were significantly related to agreement. CONCLUSIONS: Patients and providers disagreed about whether or not weight issues were discussed in a large number of primary care encounters in this study. Physicians may be able to improve care for their obese patients by focusing discussions on specific details of diet and physical activity behaviors, and by clarifying that patients perceive weight-related information has been shared.

Ecologic correlates of obesity in rural obese adults.

OBJECTIVE: We examined relationships of individual and environmental factors with obesity and trying to lose weight in rural residents. METHODS: The joint contributions of individual and environmental factors on obesity status (obese vs. morbidly obese) and trying to lose weight (yes vs. no) were evaluated using generalized estimating equations. Patients at 29 clinics in rural areas (N = 414, M age 55.0 years (SD = 15.4), 66.3% female) completed anthropometric assessments of weight and height along with survey assessments of individual sociodemographics and trying to lose weight. Rural environments were assessed on aggregated physician access, and sociodemographic context. RESULTS: Most participants (70%, M BMI = 38.3) were obese and 30% morbidly obese. A majority (73%, n = 302) of the sample was trying to lose weight. Compared to obese, morbidly obese participants were more likely to be younger, disproportionately female, not have private insurance, have more comorbid conditions, and rate themselves in worse health in comparison to their obese peers. Compared to not trying to lose weight, trying to lose weight participants were more likely to be younger, disproportionately female, have fewer comorbid conditions, and have attempted to lose weight more times through exercise. Few relationships were seen between environmental variables and obesity or trying to lose weight. CONCLUSIONS: There was no consistent pattern of relationships between environment factors and obesity or trying to lose weight was seen. Unique aspects of rural living may not be captured by traditionally available neighborhood measures.

Concordance of patient-physician obesity diagnosis and treatment beliefs in rural practice settings.

CONTEXT: Although clinical guidelines recommend routine screening and treatment for obesity in primary care, lack of agreement between physicians and patients about the need for obesity treatment in the primary care setting may be an unexplored factor contributing to the obesity epidemic. PURPOSE AND METHODS: To better understand this dynamic, we surveyed 439 obese patients (body mass index >or=30) at the time of clinic visits in 2003 at diverse primary care settings in rural Kansas and conducted same-day interviews with their physicians (N = 28). We used Spearman's correlation to describe and compare patient and physician responses. FINDINGS: Most patients were women (66%). Their mean age was 55.8 years, and mean body mass index was 37.7. Half (51%) reported discussing their weight on that visit date. Overall, 51% of patients wanted to discuss weight more often with their physician and 54% wanted to discuss weight sooner. Patients and physicians gave similar assessments of the patient's preference for discussing weight loss, how often weight was discussed at visits, and the patient's motivation for weight loss. Spearman's correlations on these variables were .33, .54, and .25, respectively (all P < .001). CONCLUSIONS: These patients and their physicians demonstrated a weak to moderate agreement on several variables crucial to initiating and continuing obesity care. Understanding patient and provider beliefs and preferences regarding obesity diagnosis and treatment is essential in designing obesity interventions for primary care.

Homelessness and smoking cessation: insights from focus groups.

Smoking prevalence among homeless persons is approximately 70%, yet little is known about tobacco use patterns or smoking cessation practices in this population. We assessed smoking attitudes and behaviors, psychosocial and environmental influences on smoking, barriers to and interest in quitting, and preferred methods for cessation among some homeless smokers. Six 90-min focus groups of current smokers (N = 62) were conducted at homeless service facilities. Participants had a mean age of 41.5 years (SD = 9.3), were predominantly male (69.4%) and African American (59%), and smoked an average of 18.3 cigarettes/day. Although most reported that they were motivated to quit, a number of barriers to quitting were identified. Participants reported that the pervasiveness and social acceptance of tobacco use in homeless settings contributed to smoking more cigarettes per day, adopting alternative smoking behaviors such as smoking cigarette butts and making their own cigarettes, and experiencing difficulty in quitting. High levels of boredom and stress also were cited as reasons for continued smoking. Smoking frequently occurred in combination with alcohol or illicit drug use or to achieve a substitute "high." Most participants (76%) reported that they planned to quit smoking in the next 6 months. Many were interested in using pharmacotherapy in combination with behavioral treatments. Results suggest that, although motivated to quit smoking, homeless smokers are faced with unique social and environmental barriers that make quitting more difficult. Interventions must be flexible and innovative to address the unique needs of homeless smokers. Smoking restrictions at homeless service facilities and funding for smoking cessation assistance in this underserved population may help to reduce prevalence.

Knowledge and perceptions of colorectal cancer screening among urban African Americans.

OBJECTIVE: To explore colorectal cancer (CRC) screening knowledge, attitudes, barriers, and preferences among urban African Americans as a prelude to the development of culturally appropriate interventions to improve screening for this group. DESIGN: Qualitative focus group study with assessment of CRC screening preferences. SETTING: Community health center serving low-income African Americans. PARTICIPANTS: Fifty-five self-identified African Americans over 40 years of age. MEASUREMENTS AND MAIN RESULTS: Transcripts were analyzed using an iterative coding process with consensus and triangulation on final thematic findings. Six major themes were identified: (1) Hope--a positive attitude toward screening, (2) Mistrust--distrust that the system or providers put patients first, (3) Fear--fear of cancer, the system, and of CRC screening procedures, (4) Fatalism--the belief that screening and treatment may be futile and surgery causes spread of cancer, (5) Accuracy--a preference for the most thorough and accurate test for CRC, and (6) Knowledge--lack of CRC knowledge and a desire for more information. The Fear and Knowledge themes were most frequently noted in transcript theme counts. The Hope and Accuracy themes were crucial moderators of the influence of all barriers. The largest number of participants preferred either colonoscopy (33%) or home fecal occult blood testing (26%). CONCLUSIONS: Low-income African Americans are optimistic and hopeful about early CRC detection and believe that thorough and accurate CRC screening is valuable. Lack of CRC knowledge and fear are major barriers to screening for this population along with mistrust, and fatalism.

Predictors of fecal occult blood test (FOBT) completion among low-income adults.

BACKGROUND: Fecal occult blood testing (FOBT) can reduce colorectal cancer (CRC) mortality. Unfortunately, CRC screening is underutilized. Sociocultural mediators of FOBT adherence have not been extensively studied in lower income, minority populations. This study prospectively studied FOBT return in a low-income, multiethnic population. METHODS: Participants (N = 298), aged > or =40 years, were surveyed and given FOBT kits with instructions. Those not returning kits within 30 days received a reminder telephone call. Bivariate and multivariate analyses assessed predictors of FOBT card return at 90 days. RESULTS: Participants (median age = 48) were predominately African American (69%), without private insurance (88%), and of low income. The largest group of participants preferred FOBT alone (46%), followed by whatever my doctor recommends (19%), endoscopy + annual FOBT (16%), endoscopy alone (14%), and no screening (5%). In multivariate analyses, FOBT return was predicted by age (OR = 1.05) and lack of reported FOBT barriers (OR = 3.81). Among those > or =50 and not up-to-date with screening, FOBT return was predicted by cancer fatalism (OR = 0.83). FOBT barriers were associated with age (OR = 0.96), less than high school education (OR = 2.05), and less physician trust (OR = 2.12). Endoscopy barriers were associated with age (OR = 0.93), less physician trust (OR = 1.95), and female gender (OR = 3.45). CONCLUSIONS: Younger individuals and those with less education, less trust in health care providers, and more fatalistic beliefs are at risk for CRC screening non-adherence. Strategies addressing common misconceptions should improve CRC screening rates in low-income, multiethnic populations.

Knowledge, attitudes, and beliefs about end-of-life care among inner-city African Americans and Latinos.

OBJECTIVE: This project explored end-of-life care preferences and barriers among low-income, urban African Americans and Latino/Hispanic Americans (Latinos) to uncover factors that may influence hospice utilization. METHODS: Focus groups were conducted separately for African Americans (4 groups, n = 26) and Latinos (4 groups, n = 27). Transcripts were coded and analyzed using consensus and triangulation to identify primary themes. RESULTS: Four preference themes and four barriers were identified. Results were largely similar across the two groups. Both preferred having families provide care for loved ones but expressed desire to reduce caretaker burden. Groups emphasized spirituality as the primary means of coping and valued the holistic well-being of the patient and family. Barriers reported were closely tied to access to care. Participants reported low hospice utilization because of lack of awareness of hospice and the prohibitive cost of health care. Latinos were more likely to report language barriers, while African Americans were more likely to report mistrust of the system. CONCLUSIONS: African Americans and Latinos in this study were highly receptive to end-of-life care that would provide relief for patients and caregivers and emphasize spirituality and family consensus. Improving awareness of hospice services would likely increase utilization.

The utilization of physical therapy in a palliative care unit.

BACKGROUND: In the supportive oncology and palliative care settings, rehabilitation interventions are often overlooked and underutilized, despite high levels of functional disability in these patients. As a result, little is known about the utilization or effectiveness of rehabilitation interventions in palliative care populations. OBJECTIVE: To assess the utilization of physical therapy (PT) in a hospital-based palliative care unit, to characterize functional disabilities in patients who received PT, and to identify factors related to functional improvement following a course of PT. METHODS: Retrospective chart review of 100 patients (mean age 70 years, 97% male) discharged from the Milwaukee Veterans Hospital Palliative Care unit over 15 months. Activities of daily living (ADL) performance scores were recorded on admission, at 2 weeks, and at completion of the PT program and correlated with demographic and disease-related variables. RESULTS: Thirty-seven patients received a formal PT assessment, and 18 patients underwent PT. The most common functional disabilities in patients who received PT were deconditioning, pain, imbalance, and focal weakness. Ten patients demonstrated improvement in ADL function at 2 weeks. Six patients completed the course of PT. Albumin was significantly correlated with functional improvement. When controlling for albumin, patients with diagnosis of dementia were more likely to show improvement in functional status than patients without a dementia diagnosis. CONCLUSION: PT assessment and utilization were uncommon in this group. When utilized, PT benefited 56% of patients. Factors related to functional improvement following a PT course were a higher albumin level and a diagnosis of dementia. Prospective trials of PT in palliative care patients are needed to better define response rate and predictors of response.

Assessing overweight, obesity, diet, and physical activity in college students.

The authors surveyed 738 college students aged 18 to 27 years to assess overweight, obesity, dietary habits, and physical activity. They used BMI (body mass index) > or = 25 kg/m2 or BMI > or = 85th percentile and BMI > or = 30 kg/m2 or BMI > or = 95th percentile to estimate overweight and obesity in those aged < or = 19 years. To define overweight and obesity in those > or = 20 years, they used BMI > or = 25 kg/m2 and > or = 30 kg/m2. They found overweight rates of 21.6% using BMI directly and 16.2% using BMI percentile and obesity rates of 4.9% using BMI directly and 4.2% using BMI percentile. More than 69% of the participants reported < 5 servings of fruits and vegetables per day and more than 67% reported < 20 g of fiber per day; participants reported physical activity on fewer than 3 d/wk. Most college students are not meeting dietary and physical activity guidelines, suggesting the need for prevention interventions and increased understanding of overweight in college students.