From physician-centered to community-oriented perspectives on health care: assessing the efficacy of community-based training.

PURPOSE: To understand the influence of a community-based child advocacy block rotation on the perspectives of first-year pediatric residents and whether this influence persists. METHOD: The authors conducted semistructured interviews to assess the impact of the training program on pediatrics residents' perspectives regarding child advocacy and their understanding of the role of the community members and community-based assets in child advocacy. Three cohorts of first-year residents at the University of California, Davis, participated in the two-week community collaborative rotation from 2000 03. Two cohorts of 23 first-year residents were interviewed. In 2003, the first cohort of nine third-year residents was re-interviewed to assess long-term impact. Interviews were conducted before and after residents' experiences with community collaboratives. Transcripts of interviews were reviewed using an iterative process, and a coding system was applied using a qualitative software program. RESULTS: Comparison of pre- and postrotation interview data showed that residents' conceptions of advocacy shifted from ideas about being a pediatrician for the community to being a pediatrician in the community. This change in definition reflected a view of the pediatrician as facilitator, a community asset, rather than as a central administrator of child health affairs. This shift persisted through the completion of residency. CONCLUSIONS: These findings suggest that substantive interaction in a community collaborative can provide a starting point for residents to reconceptualize their role as pediatrician, for understanding the diverse contexts characteristic of children's circumstances, and for identifying and using community-based assets for improving child health. Definition changes persisted through residency and may influence residents' future behavior in clinical practice.

Evaluation of factors affecting awareness of and willingness to participate in cancer clinical trials.

PURPOSE: Annually, only 3% of patients participate in cancer clinical trials (CCTs). Barriers to accrual include lack of CCT awareness and uncertain third-party payer coverage. In January 2002, a California law (Senate Bill 37 [SB37]) required all third-party payers to reimburse patient care costs related to CCTs. We evaluated the level of awareness of patients and/or their family members/friends regarding CCTs and SB37. METHODS: We used both a written survey for patients and/or their family members and friends seen in oncology clinics, and a verbal telephone version for Cancer Information Service callers. We tested for correlations between CCT awareness and SB37 knowledge, and willingness to participate in CCTs. RESULTS: Of 1,188 respondents, 59% were aware of CCTs, 19% knew of SB37, and 36% were very likely to consider a CCT. There were significant positive correlations between CCT awareness and willingness to participate (P < .001, Spearman), and between SB37 knowledge and willingness to participate (P = .001, Pearson chi2). Reduced awareness was seen in respondents who were either black or African American (odds ratio [OR], 0.44; P = .004), Hispanic (OR, 0.56; P = .03), had an annual income less than 25,000 dollars (OR, 0.38; P < .001), or had less than a college degree (OR, 0.12 to 0.53; P < .001 to .013). Reduced willingness to participate in CCTs was seen in black or African American participants (OR, 0.38; P < .001), Asians (OR, 0.44; P < .006), or respondents aged 18 to 24 years (OR, 0.35; P = .002). CONCLUSION: These results support the hypothesis that improving CCT awareness and SB37 knowledge especially among lower income, less educated, and minority patients, may potentially overcome barriers to participation and subsequently increase accrual in California.

Asian Americans and cancer clinical trials: a mixed-methods approach to understanding awareness and experience.

Cancer clinical trials have been based on low accrual rates. Barriers to recruitment of minority populations affect the generalizability and impact of trial findings for those populations. The authors undertook a mixed-methods approach to understanding levels of awareness and experiences with cancer clinical trials. A survey was administered to new cancer patients and their caretakers (family, close friends, or other social support) at outpatient oncology clinics. Field observations of the trial accrual process also were conducted by employing the grounded theory approach in qualitative methods. Comparison of survey results for Asian-American respondents and non-Asian respondents indicated that Asians were less likely to have heard the term "clinical trial" and were more likely to define a clinical trial as "an experiment" or "a test procedure in a clinic" than non-Asians. Asians were more likely to have employer-based insurance and to report understanding issues related to cost reimbursement. Asians were less likely to have been involved in or to know someone in a trial and reported less willingness than white respondents to consider trial participation. Qualitative observations suggested that Asians who presented for a potential trial were interested in the availability of a novel cancer therapy but were not eligible for available trials. Multiple strategies will be necessary to enhance awareness of and experience with accrual to cancer clinical trials for Asians, including richer understanding and increased involvement of Asians in cancer clinical trials and greater attention to the location and diversity of the Asian population in structuring study centers and evaluating trial results.