Increasing representation and diversity in health research: A protocol of the MYHealth research training program for high school students.

BACKGROUND: Despite decades of calls for increased diversity in the health research workforce, disparities exist for many populations, including Black, Indigenous, and People of Color individuals, those from low-income families, and first-generation college students. To increase representation of historically marginalized populations, there is a critical need to develop programs that strengthen their path toward health research careers. High school is a critically important time to catalyze interest and rebuild engagement among youth who may have previously felt excluded from science, technology, engineering, and mathematics (STEM) and health research careers. METHODS: The overall objective of the MYHealth program is to engage high school students in a community-based participatory research program focused on adolescent health. Investigators will work alongside community partners to recruit 9th through 12th graders who self-identify as a member of a group underrepresented in STEM or health research careers (e.g., based on race and ethnicity, socioeconomic status, first generation college student, disability, etc.). MYHealth students are trained to be co-researchers who work alongside academic researchers, which will help them to envision themselves as scientists capable of positively impacting their communities through research. Implemented in three phases, the MYHealth program aims to foster a continuing interest in health research careers by developing: 1) researcher identities, 2) scientific literacy, 3) scientific self-efficacy, and 4) teamwork and leadership self-efficacy. In each phase, students will build knowledge and skills in research, ethics, data collection, data analysis, and dissemination. Students will directly collaborate with and be mentored by a team that includes investigators, community advisors, scientific advisors, and youth peers. DISCUSSION: Each year, a new cohort of up to 70 high school students will be enrolled in MYHealth. We anticipate the MYHealth program will increase interest and persistence in STEM and health research among groups that have been historically excluded in health research careers.

Youths' perceptions and behaviors on COVID-19 testing.

BACKGROUND: Social gatherings are frequent sources of COVID-19 infections, especially among youth. However, little is known about youth testing behaviors before and after gatherings. Our aim was to assess behaviors and perceptions of youth related to testing for COVID-19 before or after social gatherings in order to inform efforts to reduce disease spread. METHODS: Five open-ended questions were texted to participants aged 14-24 throughout the United States via MyVoice. Using a content analysis approach, two investigators reviewed responses by question, developed a codebook, and independently applied codes. Discrepancies were resolved via discussion. Code frequency and demographic data were summarized using descriptive statistics. RESULTS: Of 1204 participants, 989 responded to at least one question (RR = 94.1%). The mean age was 20.2 years (SD: 2.4 years). Most participants (80.7%) reported testing for COVID-19 at least once. Most (70.6%) were likely to test following an event, especially "[i]f someone at the gathering tested positive," while a smaller number (50.9%) endorsed testing prior to a gathering. Of youth who would not get tested, being vaccinated was the highest reported. CONCLUSION: Youth in our nationwide sample are likely to test for COVID-19 after an event, though less likely if they are vaccinated. Their desire to test is primarily driven by symptoms, exposures, and requirements. Youth are interested in increased access to home testing. Youth-centered communications regarding testing recommendations and increased test availability for youth may reduce COVID-19 spread among young people and inform future pandemic recommendations.

'You have to use everything and come to some equilibrium': a qualitative study on hypoglycemia self-management in users of continuous glucose monitor with diverse hypoglycemia experiences.

INTRODUCTION: Although continuous glucose monitoring systems (CGMs) can help reduce hypoglycemia, about one-quarter of people with type 1 diabetes (T1D) who use CGMs still either spend at least 1% of the time with dangerously low blood glucose or develop severe hypoglycemia. This study explored experiences around hypoglycemia self-management in people who are living with T1D and using CGMs to identify factors contributing to hypoglycemia development. RESEARCH DESIGN AND METHODS: Purposive sampling and semistructured interviews with 28 respondents with T1D and using CGMs were conducted to explore experiences around hypoglycemic episodes and hypoglycemia self-management during CGM use. Open coding and thematic analysis were employed to identify emergent themes related to hypoglycemia experiences. RESULTS: About one-third of respondents each respectively spent 0%, 0.1%-0.9% and ≥1% of time in level 2 hypoglycemia; 39% had impaired awareness of hypoglycemia and 32% had severe hypoglycemia in the past 6 months. Four themes were generated: (1) prioritizing symptoms over CGM data (subthemes: hypoglycemia symptoms for confirming hypoglycemia and prompting management actions; minimal management actions without hypoglycemia symptoms); (2) distraction from the demands of daily life; (3) concerns about hypoglycemia management choices (subthemes: fear of rebound hyperglycemia; other health consequences related to sugary food consumption; aversions to treatment foods and treatment food consumption); and (4) social influences on management choices (subthemes: positively perceived social support and inclusion; unwanted attention to oneself or concerns about inconveniencing others; social stigma and criticism related to hypoglycemia and CGM use). CONCLUSIONS: Despite using CGMs, people with T1D can face a complex biopsychosocial process of managing hypoglycemia. Interventions for addressing psychosocial and behavioral barriers are needed to improve hypoglycemia self-management in those who continue to face challenges in minimizing hypoglycemia while using CGMs.

Patient-Reported Usefulness and Challenges in Using Hypoglycemia-Informing Features of Continuous Glucose Monitors to Manage Hypoglycemia.

PURPOSE: The purpose of this study series, which involves a questionnaire survey and qualitative interviews, was to (a) evaluate patient-reported usefulness of continuous glucose monitor (CGM) hypoglycemia-informing features and (b) identify challenges in using these features (ie, CGM glucose numbers, trend arrows, trend graphs, and hypoglycemia alarms) during hypoglycemia in adults with type 1 diabetes (T1DM). METHODS: A cross-sectional questionnaire survey study was conducted with adults who have T1DM and were using CGMs to assess the perceived usefulness of hypoglycemia-informing features. A semistructured interview study with T1DM CGM-using adults and inductive thematic analysis were subsequently performed to identify challenges in using CGM hypoglycemia-informing features to manage hypoglycemia. RESULTS: In the survey study (N = 252), the CGM glucose numbers, trend arrows, trend graphs, and hypoglycemia alarms were found to be very useful by 79%, 70%, 43%, and 64% of participants, respectively. Several challenges in using these features to manage hypoglycemia were identified in the qualitative study (N = 23): (1) hypoglycemia information not fully reliable,; (2) unpredictability of future blood glucose levels, (3) lack of awareness about how information can be used, and (4) disruptions associated with information. CONCLUSIONS: Although the majority of T1DM adults found their CGMs' hypoglycemia-informing features helpful, challenges in optimally using these features persisted. Targeted knowledge and behavioral interventions could improve CGM use to reduce hypoglycemia.

A Delphi-Style Evaluation of a Skin Assessment Simulation Using Clinical Vignettes and a Breast Health Training Tool.

INTRODUCTION: Breast and skin assessment are both required clinical skills across health professional training programs. The breast is an ideal "canvas" for the development of a simulation exercise focused on the identification and diagnosis of skin conditions that could present anywhere on the body alongside unique conditions specific to the breast and nipple-areolar complex. A skin assessment simulation on a breast model has not been described. METHODS: Investigators developed 20 clinical vignettes for breast and skin conditions (ie, features) depicted on a set of 10 single silicone breast models in 4 skin tones. A modified Delphi approach was used to evaluate the appropriateness of the clinical vignettes and realism of features. A convenience sample of 136 licensed physicians was recruited online. In round 1, participants rated the realism of features and suggested descriptors for each feature. In round 2, participants rated their agreement with descriptors from round 1, selected a diagnosis based on clinical vignettes, and assessed the utility of the Breast Health Training Tool for health professionals. RESULTS: In round 1, participants (n = 38) agreed (5.1/6) that the features were realistic. In round 2, participants (n = 24) agreed (4.6/6) with the descriptors. Most (>50%) participants agreed on a diagnosis for each feature. Participants (n = 27) agreed (5.3/6) that this tool is useful for health professional education. CONCLUSIONS: This is the first evaluation of a simulation tool for teaching breast examination and identification of skin conditions on the nipple-areolar complex and breast tissue in multiple skin tones, simultaneously filling the gap in women's breast, lactation, and skin health education.

An Application of Kane's Validity Framework to Evaluate Formative and Summative Assessment Instruments for Telesimulations in Clinical Lactation.

INTRODUCTION: Health professional learners have limited exposure to breastfeeding patients from diverse backgrounds in clinical rotations. Instead, simulation-based training is used for lactation skills training. There are no validated or standardized simulations and assessment rubrics for lactation. In this pilot, breastfeeding telesimulations with standardized patients (SPs) wearing a high-fidelity breast model matching their skin tone were developed. The validity of Formative and Summative Assessment Rubrics (FAR, SAR) were assessed following Kane's validity framework. The objective was to provide initial evidence for the validity of the FAR and SAR as constructs of competence in lactation support at the entry to practice or practice level. METHODS: Three breastfeeding case scenarios, FAR, and SAR were developed and evaluated with clinical lactation specialists (evaluators, n = 17) and SPs. The FAR was used in practice telesimulations where SPs' (n = 14) performance and telesimulation feasibility were assessed. The FAR was updated in preparation for a pilot study where medical students (n = 13) completed the 3 telesimulations. In the pilot, the updated FAR was used by SPs (n = 6) to assess medical students' performance of clinical skills. After the pilot, rubrics were updated after focus groups with SPs and discussions with evaluators. Evaluators (n = 3) graded students' posttelesimulation documentations using the SAR. Cronbach ɑ level and the intraclass correlation coefficient were assessed iteratively to collect evidence for the scoring, generalizability, and extrapolation of the FAR and SAR according to Kane's framework. RESULTS: The FAR and SAR were found to have acceptable internal consistency and moderate to high interrater reliability (intraclass correlation coefficient, 0.55-0.94), which provided evidence for scoring and generalizability of the instruments. Evaluators agreed that SPs' performances were realistic (5.6/6), and SPs' feedback was organized (5.5/6) and helpful (5.6/6), which provided evidence for extrapolation. CONCLUSIONS: Initial evidence for validity of scoring, generalization, and extrapolation FAR and SAR (according to Kane's framework) in assessing health professional learner's performance of clinical lactation skills has been presented. These results from a pilot study suggest that the FAR and SAR are reliable instruments for assessing learners' clinical performance in a breastfeeding-focused telesimulation where the SP wears a high-fidelity breast model matching their skin tone. Additional studies will be required to collect evidence according to all 4 categories of Kane's framework for the validity of the FAR and SAR.

Development of Team Behavior Skills and Clinical Lactation Competence Among Medical Students Engaging in Telesimulations with Standardized Patients.

Objective: The aims of this pilot feasibility study were to determine if telesimulations with standardized patients (SPs) wearing high-fidelity breast models impact students' team behavior and clinical competence in lactation support. Materials and Methods: Medical students (N = 19) completed five telesimulations: Cases 1, 2, 5 in a team, 3 as individual, and 4 randomized. SPs used the Formative Assessment Rubric (FAR) to evaluate interpersonal and clinical competence. Collaboration skills within team-based telesimulations (Cases 2 and 4) were rated using the Interprofessional Collaborator Assessment Rubric (ICAR). Satisfaction data were collected from a focus group and written evaluation. Descriptive statistics were calculated for FAR, ICAR, and written evaluations. Appropriate nonparametric tests were used to measure FAR and ICAR differences over time or between team and individual telesimulations and the relationship between FAR and ICAR scores. Content analysis was used to generate themes from focus group data. Results: Learners' interpersonal and lactation-specific competence improved over time (p = 0.003 and 0.009, respectively). Learners were able "to accept responsibility for their actions" more but spent less time "seeking perspectives from peers" in Case 4 compared with Case 2 (p = 0.01 and p < 0.001, respectively). Themes from the focus group related to the value of team telesimulations to learn clinical lactation skills and learn about one's role in a team. Learners agreed they developed clinical lactation skills (>4.5/5-pt). Conclusions: Opportunities to work collaboratively in telesimulations with a SP prepare learners for professional collaborations to effectively care for breast/chestfeeding dyads.

A pilot study to evaluate the effect of classroom-based high-fidelity simulation on midwifery students' self-efficacy in clinical lactation and perceived translation of skills to the care of the breastfeeding mother-infant dyad.

BACKGROUND: Midwives are expected to provide timely and skilled support to breastfeeding mothers, yet it is not clear whether and how midwifery students receive training in clinical lactation. The primary objective of this pilot study was to evaluate the impact of a classroom-based breastfeeding simulation on nurse-midwifery students' self-efficacy in lactation skills. The secondary objective was to describe students' exposure to breastfeeding patients in the classroom and in clinical settings. METHODS: A pilot study using a prospective cohort study design and convenience sampling was completed between September 2017 and April 2018. Two simulation-based workshops were developed for the classroom setting in alignment with breastfeeding-focused competencies for midwives and lactation professionals. The workshops were integrated into the nurse-midwifery curriculum at a US-based program. Two Self-Efficacy Surveys (defined, 7-point Likert Scale) were developed and used to measure baseline and continuing self-efficacy in breastfeeding skills among students. Two Practice Patterns instruments, adapted from the American Academy of Pediatrics breastfeeding curriculum, were used to define the setting, quantity, and types of nurse-midwifery students' breastfeeding-related exposures. Students participated in a one-hour focus group upon completion of the study. RESULTS: In this pilot study, nurse-midwifery student participants (N = 9) reported a 14% increase (P < .0001) in their perceived self-efficacy in basic and advanced clinical lactation skills after completing both workshops. The nurse-midwifery students reported dozens of encounters with diverse breastfeeding patients over a six-month period during which they performed a wide variety of clinical lactation skills. The focus group revealed most students (n = 5/9) would like more time to practice clinical lactation skills in a simulated environment and some indicated a desire to have more exposure to challenging versus common (n = 2/9) of breastfeeding concerns. CONCLUSIONS: In this work, we demonstrate the first high-fidelity lactation simulation in a classroom setting in a healthcare professional training program. Midwifery educators and researchers can adapt the framework and instruments presented in this pilot study to determine the effect of educational interventions on students' translation of skills to breastfeeding mother-infant dyads. Likewise, this is the first study to define the number and type of breastfeeding-related clinical exposures among nurse-midwifery students.

The Efficacy of Hybrid Telesimulation with Standardized Patients in Teaching Medical Students Clinical Lactation Skills: A Pilot Study.

Introduction: Medical students lack competencies in clinical lactation. We determined the effect of hybrid telesimulation with a standardized patient (SP) on medical students' clinical performance in lactation support. We assessed students' engagement and satisfaction with the experience. Materials and Methods: Undergraduate medical students (n = 13) completed (1) preparatory case scenarios with multiple-choice questions and (2) three telesimulations with SPs wearing a high-fidelity breast model. Students had the option to complete the Encounter Documentation. SPs used the Formative Assessment Rubric (FAR) to evaluate students' interpersonal skills and clinical lactation experts used the Summative Assessment Rubric to evaluate documentation skills. Investigators collected satisfaction data from a focus group and written evaluation. Dunn's multiple comparison and Freidman tests were used to measure differences in FAR scores between cases and telesimulations. Qualitative data were analyzed using thematic analysis. Results: Most students (70%) attempted case questions multiple times and scores improved (p < 0.0001) between attempts. FAR scores suggest students were prepared for telesimulations (5.5/6-pt Likert) and interpersonal skills were appropriate (5.4/6), with no differences by case (p = 0.11). FAR scores increased between telesimulation 1-2 (+24.5/114, p = 0.002) and 2-3 (+17.5/114, p = 0.014). Students were satisfied with the experience and would recommend it to classmates (both 4.6/6). Thematic analysis revealed feedback regarding interpersonal skills was helpful. Conclusions: Medical students must develop skills to support breastfeeding in virtual settings. Telesimulation can be incorporated into existing curricula to support clinical lactation competencies.

Midwifery students better approximate their self-efficacy in clinical lactation after reflecting in and on their performance in the LactSim OSCE.

BACKGROUND: Midwives are expected to support women with lactation initiation and maintenance. Midwifery students engaged in a simulation-based exercise (LactSim OSCE) where they role-played the clinician and the breastfeeding patient by wearing a high-fidelity breast model. We provided participants opportunities for reflecting in and on practice to compare their perceived self-confidence in clinical lactation skills to actual clinical performance. We also describe feasibility of implementing the LactSim OSCE with an emphasis on preparation and time spent on tasks during the OSCE. METHODS: Audio-video recordings from the LactSim OSCE were viewed and assessed using a technical skills checklist by an independent rater and by the study participants as part of the self-reflection. Mixed data on participants' self-efficacy in clinical lactation, experience with the LactSim OSCE, and self-assessment of clinical performance were collected in survey instruments and a focus group. Time spent on each component and clinical lactation skill during the LactSim OSCE was documented. RESULTS: Immediately following the LactSim OSCE, participants' confidence in clinical lactation was high (5.7/7), but after a guided video reflection exercise, their self-efficacy was 4.4/7. Participants spent approximately 2 of the allotted 10 min per case scenario discussing the OSCE logistics due to inadequate preparation. Participants spent approximately 2 min of the total encounter performing hands-on clinical lactation skills by touching, looking at, or using the high-fidelity breast model worn by their peer. CONCLUSION: We described the development and evaluation of the first simulated experience in clinical lactation with all three components of fidelity: conceptual, psychological, and physical. Multiple opportunities for reflecting on performance allowed the nurse-midwifery students to evaluate their competence in decision-making, technical, and counseling skills which resulted in a more realistic approximation of their perceived self-confidence in breastfeeding skills. Another innovation of this pilot work is the documentation of how long a learner spends on various tasks relevant to lactation support in a simulated encounter. Our findings highlight the importance of providing multiple opportunities for self-reflection using guided video reflection and checklists for objective self-assessment in the clinical lactation field.

Development and evaluation of a high-fidelity lactation simulation model for health professional breastfeeding education.

BACKGROUND: A key reason for premature cessation of breastfeeding is inadequate support from healthcare providers. Most physicians and nurses do not feel confident in their ability to support families with breastfeeding initiation or maintenance. Increasing health professional confidence in clinical lactation skills is key to improving maternal and child health outcomes. High-fidelity (realistic) simulators encourage learner engagement, resulting in increased clinical skills competency, confidence, and transfer to patient care. Lactation educators teach with low-fidelity cloth and single breast models. There are no high-fidelity breast simulators for health professional education in clinical lactation. DEVELOPMENT AND EVALUATION OF A HIGH-FIDELITY LACTATION SIMULATION MODEL: In this commentary we describe the development of a high-fidelity Lactation Simulation Model (LSM) and how physician residents, nurse-midwifery students, and clinical lactation experts provided feedback on LSM prototypes. LIMITATIONS: The user-testing described in this commentary does not represent comprehensive validation of the LSM due to small sample sizes and the significant conflict of interest. CONCLUSION: For breastfeeding rates to improve, mothers need support from their nurses, midwives, pediatricians, obstetricians and gynecologists, and all healthcare staff who interact with pregnant and lactating women. Clinical education with high-fidelity breastfeeding simulators could be the ideal learning modality for trainees and hospital staff to build confidence in clinical lactation skills. The ability of a high-fidelity breastfeeding simulator to increase a learner's lactation knowledge and psychomotor skills acquisition, retention, and transfer to patient care still needs to be tested.

Assessing Application-Based Breastfeeding Education for Physicians and Nurses: A Scoping Review.

BACKGROUND: Physicians and nurses are expected to support breastfeeding mothers. However, there is a lack of standardized lactation education throughout training programs and hospitals. As a result, providers lack the necessary confidence and skills to guide mothers throughout the breastfeeding experience. The hands-on nature of breastfeeding management demands the implementation of application-based learning tools to improve skills retention and patient breastfeeding outcomes. RESEARCH AIM: In this scoping review, we aimed to critically assess the types of application-based breastfeeding management learning tools reported within medical and nursing professions and the evaluation methods of learner and patient outcomes. METHODS: The authors searched the literature to identify peer-reviewed articles published between 2000 and 2018 with medical or nursing students, residents, or professionals as the target learner group in an application-based educational intervention. Both authors independently assessed the content in the resulting articles, with specific focus on teaching methods, curricular development, and the learning outcomes reported within each study. RESULTS: Ten articles matched the inclusion criteria and were included in the final review, including five studies from the medical field and five from the field of nursing. Use of real patients was a common method for application-based skills training, followed by role playing and use of standardized patients. Teaching and evaluation methods varied widely across the studies. CONCLUSION: The results align with existing literature in finding a dearth of high-quality studies assessing breastfeeding education among physicians and nurses. The variability in teaching and evaluation methods indicates a lack of standardization in breastfeeding education between institutions.