Educational strategies used to improve the knowledge, skills, and attitudes of health care students and providers regarding implicit bias: An integrative review of the literature.

Background: The thoughts, feelings, and attitudes health care professionals unconsciously have about patients can negatively impact patients' health outcomes. Systematic reviews related to implicit bias in health care providers have uncovered negative implicit bias towards older adults, people of color, people with disabilities, psychiatric patients, patients who are obese, people of low socioeconomic status, and women. Implicit bias impacts the quality, safety, and competence of care delivered; interactions between patients and providers; and patient approval of treatment recommendations. Health care professions students and health care providers need to participate in evidence-based educational strategies to manage and diminish bias. Objective: To review the evidence regarding educational strategies used with health care professions students and providers to improve their knowledge of implicit bias, reduce bias, and improve attitudes about bias. Design: Integrative review. Methods: The literature review was completed in July 2020 with two updates performed in February 2021 and June 2021 using nine databases including Academic Search Complete™, Embase®, ERIC®, Ovid, PubMed®, Scopus®, and Web of Science™. Key terms used related to education, health care professions' students, health care providers, implicit, bias, incivility, microaggression, and microassult. Publications dates from 2011 to 2021 were included. Covidence software was used for the initial screening and for full-text analysis. Results: Thirty-nine articles were analysed for this review. The most commonly used educational strategies to instruct about principles of implicit bias include discussion groups, simulation and case-based learning, pre-tests for awareness, use of expert facilitators, commitment to action/change, and debriefing. Common components of successful strategies include thoughtful program planning, careful selection of program facilitators (who are content experts), support of participants, and a system-level investment. Conclusions: Diverse educational strategies successfully addressed implicit bias across studies. Recommendations for future studies includes addressing limitations in sampling strategies and data collection to clarify relationships between educational strategies and participant outcomes. Educational opportunities are warranted that challenge health care professionals to explore their implicit bias towards others in an effort to provide care that considers diversity, equity, and inclusion and also limits personal implicit bias.

Interpersonal Violence: What Undergraduate Nursing Students Know.

A program evaluation of undergraduate nursing curricula content was completed and survey developed to assess undergraduate nursing students' knowledge about interpersonal violence. Students electively answered a 43-question survey regarding interpersonal violence as a public health problem. The sample included 104 traditional and accelerated undergraduate nursing students. Increasing scores during undergraduate program enrollment suggests that students receive some content on violence from the undergraduate curriculum. This study provides data about curricular deficits and proposes content revisions to prepare nursing students to address violence in patient populations.

Life is a highway: Driver's license acquisition and social determinants for youth in foster care and their non-foster care peers.

BACKGROUND: Data regarding the connection between driver licensure and social determinants for youth could provide insight into the impact of driver license acquisition. These relationships are important for youth overall and particularly for foster youth given that adolescents in foster care obtain driver's licenses less often than their non-foster care peers. This integrative review explores the association between driver licensure and social determinants. METHODS: Whittemore and Knafl guidelines were used to conduct the integrative review. The articles were identified in collaboration with an expert in library science and public health. Results were organized by the Healthy People 2030 (HP 2030) Social Determinants of Health (SDOH) model. RESULTS: Six studies were included. Social and community context included social support structures helping youth get driver's licenses. Economics, including income and education, influenced license acquisition. Driver license acquisition was associated with improved well-being, security, and mental health. CONCLUSION: While fewer of those living in urban, walkable neighborhoods with access to public transportation were licensed, results from other studies suggest that car access is associated with psychological well-being. Further, licensure is disproportionately lower for populations historically marginalized from equal housing, education, and employment opportunities. Licensure plays a role in well-being.

Summative Content Analysis for Understanding of Romantic Relationships Among Rural Mexican American Adolescent Women.

An understanding of romantic relationships among adolescent Mexican-American females is lacking yet needed to provide culturally appropriate sexual health interventions. Although explored among other populations, romantic relationships among adolescents in rural settings is under-studied. This study explores romantic relationships for rural Mexican American female adolescents as a component of sexual health promotion. Rural Mexican-American adolescent females (n = 82) aged 14-18 years were recruited via convenience sampling at a rural health clinic. They completed open-ended individual interviews describing romantic relationships. Responses to open-ended questions were analyzed using summative content analysis. The majority reported sexual activity (62.2%) of which 23.5% had been pregnant. Summative content analyses identified personal characteristics and relationship characteristics as main categories with eight additional subcategories from responses. Sex was reported as what men wanted from women while physical attractiveness was perceived as important for both genders in development of romantic relationships. They prioritized other relational and personal characteristic such as integrity, and partner treatment of self and others. More obesity was present among those reportedly in romantic relationships. Description of parental roles as a component of romantic relationships was not present. Addressing adolescent romantic relationship with an emphasis on what male and female adolescents want or perceive as expected from relationships, long-term outcomes of relationships and on parental roles may enhance sexual health among rural Mexican-American adolescent populations. This study addresses a gap in literature by exploring romantic relationships for rural Mexican American female adolescents. This understanding of romantic relationships augments existing sexual health programing for these adolescents.

Health out of foster care as young adults age out of foster care: A phenomenological exploration of seeking healthcare services after aging out of the US foster care system.

Some adolescents in the United States who have been abused and/or neglected by caregivers and placed in permanent custody of the state leave, or "age out" of foster care at 18 years of age. Poor health outcomes among individuals who age out are notable, yet few studies describe the phenomenon of seeking healthcare services after leaving foster care. The investigators specifically queried the phenomenon of seeking healthcare services after foster care drawing from the Phenomenology of Practice approach. We interviewed 13 young adults who aged out of care. Investigators extracted lived experience descriptions (LEDs) from interview transcripts and analyzed under phenomenological themes. Healthcare experiences were marked by avoiding self-disclosure, having no choice but to wait, missing family history, and relying on the kindness of strangers. Healthcare providers who integrate the findings into care delivery models will engage young adults with more understanding and sensitivities of ethical practice.

The influence of social determinants of health among young adults after they have left foster care in the US.

AIMS AND OBJECTIVES: To describe the influence of the social determinants of health on health care seeking among young adults after they left foster care. BACKGROUND: Extensive research suggests that stakeholders in foster care systems throughout the world struggle to consistently and effectively manage the health and well-being of youth. These struggles extend beyond time in foster care as indicated by poor health and social outcomes throughout the life course. Evidence that describes how young adults address health and related social needs after leaving foster care is missing. DESIGN: A phenomenological design, Phenomenology of Practice, was used to collect data. Content analysis was used to analyse the data, using constructs from the Healthy People 2020 SDOH Model to organise the data. METHODS: Thirteen young adults who left foster care in the southwestern US were recruited using convenience sampling. Data were collected via individual interviews. RESULTS: Young adults formerly in foster care reported using and lacking social support networks to navigate SDOH. The interrelatedness of SDOH on health outcomes after foster care is evident. CONCLUSIONS: Social support networks can help explain how young adults are both able and unable to navigate systems to address health issues. Evaluating social networks used to access care is an important aspect of assessment and intervention for these vulnerable young adults. RELEVANCE TO CLINICAL PRACTICE: Healthcare providers facilitate healthcare access for young adults who have been in foster care through evaluation of social determinants. Assessment and care planning based on social determinants for those who have been in foster care are critical to ensure the efficacy of interventions designed to address health outcomes. Social support systems are key factors for young adults formerly in foster care to access resources, substantiating the need for ongoing assessment and development of these support systems.

Integrative Review: Delivery of Healthcare Services to Adolescents and Young Adults During and After Foster Care.

The purpose of this integrative review is to summarize evidence describing delivery of healthcare services to adolescents while in foster care and to young adults after they exit foster care. The long-term, deleterious effect of abuse and/or neglect by caregivers among youth who have been placed in foster care is grounded in empirical evidence demonstrating the relationship between long-term health needs and exposure to trauma in childhood. Evidence is needed to provide culturally-specific care and also to identify knowledge gaps in the care of adolescents and young adults who have been in the foster care system. Peer-reviewed research studies published between 2004 and 2014 that include samples of youth 12 to 30 years of age are included in the review. Eighteen studies met inclusion criteria for the review. Physical and behavioral healthcare needs among youth with foster care experience are significant. The ability to adequately meet health needs are inextricable from the ability to negotiate resources and to successfully interact with adults. Challenges that youth with foster care histories experience when transitioning into young adulthood are comparable to other populations of vulnerable youth not in foster care. Nurses must use each healthcare encounter to assess how the social determinants of health facilitate or impede optimal health among youth with foster care experience. The development of integrated intervention strategies to inform best practice models is a priority for current and former foster care youth as they transition into young adulthood.

The Meaning of Weight: A Big Way of Life for Rural Mexican-American Adolescent Men and Caregivers.

OBJECTIVE: To describe the meaning of body weight among rural Mexican-American adolescents (RMAA) and an influential person (IP) of their social network. DESIGN AND SAMPLE: This is qualitative descriptive study. Convenience sampling was used to recruit RMAA seeking care at a rural primary care-based clinic. Content analysis was used to identify categories and subcategories. Fifteen male adolescents and 14 IPs were interviewed (n = 29). MEASURES: Individual interviews were conducted using a semi-structured questionnaire. RESULTS: Participants described body weight through family norms, body size, and history of heart disease or diabetes. Cultural scripts were used to describe weight gain, judgment of size, and resource limitations. CONCLUSIONS: Health care providers must evaluate cultural scripts associated with body size to develop interventions that are derived from the meaning ascribed to weight status rather than simply based on evidence-based standards. ClinicalTrials.gov Identifier: NCT01387646.

Retrospective chart review of obesity and episodic and chronic illness among rural Mexican-American adolescents accessing rural health clinic services.

Obesity impacts the physical and psychological health of children and adolescents, and is a risk factor for development of episodic and chronic illness. Rural Mexican-American adolescents are at risk for obesity and associated chronic illnesses.The study used a retrospective chart review of data collected routinely in a rural health clinic setting from 1 January 2005 to 31 December 2010 to assess incidence of overweight/obesity status and episodic or chronic illness among Mexican-American adolescents aged 12-18 years. Analyses included body mass index, age, gender, and episodic or chronic illness diagnoses. Two hundred twelve charts were audited; women (n = 114, 53.8%), men (n = 98 46.2%); normal (n = 105, 49.5%), overweight/obese (n = 107, 50.5%). There were more female normal (n = 61, 53.5%) vs. overweight/obese (n = 53, 46.5%). More male overweight/obese (n = 54, 55.1%) than normal weight (n = 44, 44.9%). Age at first documented overweight/obesity status occurred in early adolescence (median = 13 years, mode = 12 years). Chronic illness incidence was higher among men than women, and overweight/obese vs. normal weight adolescents and in sub-categorizations by weight and specific illness. Incidence of episodic illness was higher among women than men, with variation by weight and specific illness. Disproportionately high incidence of episodic or chronic illness and overweight/obesity identified among rural Mexican-American adolescents compels intervention modification to improve effectiveness.

Assessment of mobile device and SMS Use for Diet and Exercise Information Among Rural Mexican-American adolescents.

This is a pilot study regarding the use of mobile technology and short message service (SMS) for diet and exercise among rural Mexican American adolescents (RMAA). Authors used convenience sampling to recruit RMAA seeking care at a rural healthcare clinic and conducted three focus groups (n=12). Content analysis was used to identify categories and subcategories. Participants applied diet and exercise information in their lives based on an interaction with community and through the use of use mobile devices. Culturally sensitive use of mobile devices and SMS may be a tool to provide rural adolescent populations with resources.

Retrospective chart review for obesity and associated interventions among rural Mexican-American adolescents accessing healthcare services.

PURPOSE: To report a retrospective analysis of data routinely collected in the course of healthcare services at a rural health clinic and to assess obesity incidence and associated interventions among rural Mexican-American adolescents. DATA SOURCES: Two hundred and twelve charts reviewed; 98 (46.2%) males and 114 (53.8%) females. Data extracted included Medicaid exams conducted at the clinic within 5 years. Equal overweight or obese (n = 105, 49.5%), versus normal BMI categorizations (n = 107, 50.5%) documented overall and by gender. Female obesity higher (25.4%) than national norms (17.4%); male rates (25.5%) were within national norm. Interventions provided by nurse practitioners (94%) for 34.8%-80% of overweight/obese had limited follow-up (4%). Obesity incidence markedly increased between 13 and 18 years of age without associated interventions; 51.4%-75.6% without interventions. CONCLUSIONS: Obesity is a healthcare problem among rural Mexican-American adolescents accessing care at the rural health clinic. Obesity intervention and follow-up was suboptimal within this setting. Rural and ethnic minority adolescents experience health disparities concerning obesity prevalence and remote healthcare access. IMPLICATIONS: Obesity prevention and treatment during adolescence is a national health priority given physiologic and psychological tolls on health and potential for obesity into adulthood. Obesity assessment and translation of evidence-based interventions for rural Mexican-American adolescents at rural health clinics is implicated.

Sexual risk behavior and STI health literacy among ethnic minority adolescent women.

Although information is available for prevention of sexually transmitted infection (STI/HIV), adolescents continue to engage in high risk sexual behavior particularly ethnic minority adolescent women with histories of STI or abuse. A description therefore of STI/HIV knowledge and sexual risk behavior among these women is indicated for modification of prevention efforts for sexual health promotion. African-American (n=94) and Mexican-American (n=465) adolescent women 14-18 years of age were included in the study. Assessments of sexual risk behavior and STI/HIV knowledge among these adolescent women described Mexican-American women as at higher risk of STI, pregnancy, substance use and abuse with lower levels of STI/HIV knowledge, previous HIV testing and perceptions of risk than African-American women. A focus on Mexican-American adolescent women with histories of STI and abuse is indicated for translation of community-based health promotion interventions for amelioration of potential adverse sexual health outcomes among ethnic minority adolescent women.

Conceptualization of sexual partner relationship steadiness among ethnic minority adolescent women: implications for evidence-based behavioral sexual risk reduction interventions.

Cognitive behavioral interventions for sexual risk reduction have been less successful among ethnic minority adolescent women with histories of abuse and sexually transmitted infections (STI) than among other adolescent populations. African American and Mexican American adolescent women (ages 14-18 years, n = 548) self-reported sexual partner relationship steadiness and sexual risk behaviors via semi-structured interviews at study entry. Descriptive and bivariate analyses compared sexual risk behaviors by sexual partner relationship steadiness. Steady and unsteady relationships were conceptualized differently. Steady relationships included emotional or financial support, sexual communication, greater relationship importance, unintended pregnancy, and perceived monogamy during break-ups. Unsteady relationships were unpredictable, including sex with ex-steady partners and friends with benefits, lack of mutual respect, and poor sexual communication. Modification of sexual risk reduction interventions including conceptualizations of risk by context of sexual partner relationship status is recommended to enhance efficacy among minority adolescent women with STI or history of abuse.

Determination of LCt(50)s in anesthetized rats exposed to aerosolized nerve agents.

Nerve agents pose a threat to the respiratory tract with exposure that could result in acute compromised lung performance and death. The determination of toxicity by inhalation is important for the rational development of timely therapeutic countermeasures. This study was designed to deliver aerosolized dilute nerve agents in a dose-response manner to investigate the extent of lethality of nerve agents: soman, sarin, VX and VR. Male rats (240-270 g) were anesthetized intramuscularly with 10 mg/kg xylazine and 90 mg/kg ketamine. Following anesthesia, rats were intubated with a glass endotracheal tube (ET) and placed in a glove box. The ET was connected to a closed circuit nebulizer system (Aeroneb, Aerogen, Inc.) that delivered a particle size of < 2.0 µm and was in series between the ventilator and the ET. Nerve agents were delivered by a small animal ventilator set for a volume of 2.5 mL × 60-80 breaths/min. VX or VR were nebulized and delivered in concentrations ranging from 6.25-800 µg/kg over a 10-min exposure time period. Sarin (GB) or soman (GD), 6.5-1250 µg/kg, were delivered in a similar manner. Lethality by inhalation occurred either during the 10-min exposure period or less than 15 min after the cessation of exposure. Survivors were euthanized at 24 h postexposure. LCt(50) estimates (± 95% confidence intervals [CIs]) were obtained from the sequential stage-wise experiments using the probit analysis. Probit analysis revealed that the LD(50) for VX was 110.7 µg/kg (CI: 73.5-166.7), VR 64.2 µg/kg (CI: 42.1-97.8); soman (GD), 167 µg/kg (CI: 90-310), and sarin (GB), 154 µg/kg (CI: 98-242), respectively. Although VR is a structural isomer of VX, the compounds appear to be markedly different in terms of toxicity when delivered by aerosol. These relationships were converted to actual 10 min LCt(50) equivalents: VX = 632.2, VR = 367, GD = 954.3 and GB = 880 mg·min/m(3). Validation of exposure was verified by the determination of blood levels of acetylcholinesterase (AChE) across doses for the agent VR.

Reducing STIs: screening, treatment, and counseling.

Screening, treatment, and counseling for sexually transmitted infections requires a thorough assessment of psychosocial, behavioral, cultural, and clinical factors. This article offers a summary of the most recent CDC data, prevention guidelines, and steps to implementing current evidence into clinical practice.

Comparison of a theory-based (AIDS Risk Reduction Model) cognitive behavioral intervention versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection: results of a randomized controlled trial.

BACKGROUND: Ethnic minority adolescent women with a history of sexual or physical abuse and sexually transmitted infections represent a vulnerable population at risk for HIV. Community-based interventions for behavior modification and subsequent risk reduction have not been effective among these women. OBJECTIVES: To evaluate the effects of a theory-based (AIDS Risk Reduction Model) cognitive behavioral intervention model versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection at 6 and 12 months follow-up. DESIGN: Controlled randomized trial with longitudinal follow-up. SETTINGS: Southwestern United States, Metropolitan community-based clinic. PARTICIPANTS: Mexican-and-African American adolescent women aged 14-18 years with a history of abuse or sexually transmitted infection seeking sexual health care. METHODS: Extensive preliminary study for intervention development was conducted including individual interviews, focus groups, secondary data analysis, pre-testing and feasibility testing for modification of an evidence-based intervention prior to testing in the randomized controlled trial. Following informed consents for participation in the trial, detailed interviews concerning demographics, abuse history, sexual risk behavior, sexual health and physical exams were obtained. Randomization into either control or intervention groups was conducted. Intervention participants received workshop, support group and individual counseling sessions. Control participants received abuse and enhanced clinical counseling. Follow-up including detailed interview and physical exam was conducted at 6 and 12 months following study entry to assess for infection. Intention to treat analysis was conducted to assess intervention effects using chi-square and multiple regression models. RESULTS: 409 Mexican-(n=342) and African-(n=67) American adolescent women with abuse and sexually transmitted infection histories were enrolled; 90% intervention group attendance; longitudinal follow-up at 6 (93%) and 12 (94%) months. Intervention (n=199) versus control (n=210) group participants experienced fewer infections at 0-6 (0% versus 6.6%, p=.001), 6-12 (3.6% versus 7.8%, p=.005, CI 95% lower-upper .001-.386) and 0-12 (4.8% versus 13.2%, p=.002, CI 95% lower-upper, .002-.531) month intervals. CONCLUSIONS: A cognitive behavioral intervention specifically designed for ethnic minority adolescent women with a history of abuse and sexually transmitted infection was effective for prevention of infection. These results provide evidence for development of evidence-based interventions for sexually transmitted infection/HIV. Implications include translation to community-clinic-based settings for prevention of adverse outcomes regarding sexual health of adolescent women.

An exploration of young ethnic minority males' beliefs about romantic relationships.

Ethnic minority males experience a disproportionate prevalence of sexually transmitted infections and HIV. Few studies have explored the beliefs that frame romantic relationships in which sexual behavior occurs. The purpose of this study was to explore the experience of romantic relationships for young ethnic minority men who partner with adolescent women with high-risk sexual histories and the beliefs about romantic relationships that underlie these relationship choices. A phenomenologic approach was used. Two semi-structured interviews were completed with six Mexican American and two African American young adult males 19 to 26 years of age. Participants struggled to balance a desire to maintain physical and psychological closeness with partners with a desire to distance from partners in the face of unmet psychological needs. Recognition of how males struggle to balance getting needs met in romantic relationships will be necessary for the provision of culturally relevant care for males and their partners.

The path to intervention: community partnerships and development of a cognitive behavioral intervention for ethnic minority adolescent females.

Reproductive health needs for ethnic minority adolescents are a national priority given the population growth of minority adolescents in the United States. United States census reports predict minority adolescents will comprise one-third of all young persons less than 20 years of age early in the twenty-first century. Developing culturally sensitive interventions for minority adolescents includes ecological assessments of cultural priorities, community resources, disease burden, and socioeconomic conditions. These assessments must be accomplished in partnership with the local community. Understanding reproductive health needs necessarily includes an evaluation of the absence of reproductive health, namely, the prevalence of sexually transmitted infection (STI), sexual or physical abuse, unplanned pregnancy, and the risk factors that contribute to such adverse outcomes. This article describes the methodological processes utilized to conduct an ecological assessment of a community including the health, economic, and psychosocial status of, and resources available to, a target population prior to the implementation of a community-based, cognitive behavioral intervention to reduce STI, abuse, and unplanned pregnancy.

Male adolescent sexual behavior: what they know and what they wish they had known.

There is a need to involve sexual partners when addressing sexual behavior of high-risk adolescent women. This study explored men's perceptions of their role in sexual relationships with adolescent women with a history of sexually transmitted infection (STI) and abuse. The AIDS risk reduction model was used to assess sexual risk behaviors of these men for development of cognitive behavioral risk reduction interventions for themselves and partner. Qualitative interviews were conducted with African and Mexican American men (n = 14; ages 18 to 21 years), recruited via adolescent women enrolled in a control-randomized trial of behavioral interventions for reduction of unintended pregnancy, abuse, substance use, and STI. Participants varied in their perceptions of personal susceptibility to STI or HIV, access to informational resources regarding sexual behavior, and level of adult support for safer sexual behavior. These men shared perceptions of inadequate sexual health preparation, including education concerning risk, ultimately contributing to adverse outcomes of sexual behavior.