The Community Primary Care Champions Fellowship: a mixed methods evaluation of an interprofessional fellowship for physician assistants and physicians.

BACKGROUND: Primary care in the US faces challenges with clinician recruitment, retention, and burnout, with further workforce shortages predicted in the next decade. Team-based care can be protective against clinician burnout, and opportunities for interprofessional education (IPE) on professional development and leadership could encourage primary care transformation. Despite an increasingly important role in the primary care workforce, IPE initiatives training physician assistants (PAs) alongside physicians are rare. We describe the design, curriculum, and outcomes from an interprofessional primary care transformation fellowship for community-based primary care physicians and PAs. METHODS: The Community Primary Care Champions (CPCC) Fellowship was a one-year, part-time fellowship which trained nine PAs, fourteen physicians, and a behavioralist with at least two years of post-graduate clinical experience in six content pillars: quality improvement (QI), wellness and burnout, mental health, social determinants of health, medical education, and substance use disorders. The fellowship included a recurring schedule of monthly activities in self-study, lectures, mentoring, and community expert evening discussions. Evaluation of the fellowship included pre, post, and one-year follow-up self-assessments of knowledge, attitudes, and confidence in the six content areas, pre- and post- wellness surveys, lecture and discussion evaluations, and midpoint and exit focus groups. RESULTS: Fellows showed significant improvement in 24 of 28 self-assessment items across all content areas post-fellowship, and in 16 of 18 items one-year post-fellowship. They demonstrated reductions in emotional exhaustion and depersonalization post-fellowship and increased confidence in working in interprofessional teams post-fellowship which persisted on one-year follow-up assessments. All fellows completed QI projects and four presented their work at national conferences. Focus group data showed that fellows experienced collaborative, meaningful professional development that was relevant to their clinical work. They appreciated the flexible format and inclusion of interprofessional community experts in evening discussions. CONCLUSIONS: The CPCC fellowship fostered an interprofessional community of practice that provided an effective IPE experience for physicians and PAs. The learning activities, and particularly the community expert discussions, allowed for a flexible, relevant experience, resulting in personal and professional growth along with increased confidence working within interprofessional teams.

Gender-Diverse Patients' Awareness and Utilization of Gender-Affirming Laryngological Services.

OBJECTIVE: Despite gender-affirming laryngological services (GALS; eg, voice therapy or surgery) being available nationwide, there is a discrepancy between the number of transgender and gender diverse (TGD) people with vocal incongruence and those who pursue services. Primary care is an important setting for accessing gender-affirming care, including learning about GALS. The purpose of this study was to understand the relationship between access to primary care and utilization of GALS. METHODS: An anonymous cross-sectional online survey was developed in REDCap. Between June-November 2022, 187 TGD respondents answered all questions related to this analysis. We assessed the relationship between having a primary care provider (PCP) and use of GALS via logistic regression. RESULTS: Of the 167 individuals who reported having a PCP, 54% reported familiarity with GALS, compared to 45% of individuals without a PCP. Compared to the group without a PCP, a greater proportion of individuals with a PCP had received professional voice therapy (21% vs 5%) and voice surgery (3% vs 0%). Logistic regression models did not demonstrate a significant effect of primary care access on either familiarity with, or use of, GALS. CONCLUSION: Most respondents (89%) were linked to the medical community through a PCP. A greater proportion of respondents with a PCP had accessed professional voice therapy and voice surgery compared with respondents without a PCP, though this difference was not statistically significant. Increased communication between GALS providers and PCPs would raise awareness of available services and may strengthen the referral pipeline to increase access to vocal care. LEVEL OF EVIDENCE: Level III.

Resident Attitudes and Experiences with a Novel Radiology-based Transgender Curriculum: A Qualitative Study.

RATIONALE AND OBJECTIVES: Transgender persons often experience healthcare disparities due to lack of provider knowledge. With increasing gender diversity awareness and prevalence of gender-affirming care, radiologists-in-training need to be aware of the unique health considerations for this patient population. Radiology residents have limited exposure to dedicated teaching on transgender medical care and imaging during training. Development and implementation of a radiology-based transgender curriculum can help close this gap in radiology residency education. The aim of this study was to explore radiology resident attitudes and experiences with a novel radiology-based transgender curriculum, guided by the conceptual framework of reflective practice. MATERIALS AND METHODS: A qualitative approach was employed using semi-structured interviews to explore resident perspectives of a curriculum covering transgender patient care and imaging over 4 monthly sessions. Ten residents at the University of Cincinnati radiology residency participated in interviews consisting of open-ended questions. Interviews were audiotaped, transcribed, and thematic analysis was conducted across all responses. RESULTS: Four themes emerged through the existing framework: 1) impactful/memorable aspects; things learned; increased awareness; and suggestions/feedback. Prominent subthemes included patient panel and stories, physician experts sharing knowledge and experiences, link to radiology and imaging, novel concept, gender-affirming surgeries and anatomy, appropriate radiology reporting, and patient interactions. CONCLUSION: Radiology residents found the curriculum to be an effective novel educational experience that was previously unaddressed during their training. This imaging-based curriculum can be further adapted and implemented in a variety of radiology curricular settings.

Using the project ECHO™ model to teach mental health topics in rural Guatemala: An implementation science-guided evaluation.

BACKGROUND: Mental health (MH) disorders are major causes of disability in Guatemala. Unfortunately, limited academic training and funding resources make MH care inaccessible to most people in rural Guatemala. These disparities leave many indigenous populations without care. Project ECHO™ is an educational model used globally to deliver virtual training for providers in rural/ underserved communities. The aim of this project was to implement and evaluate a Project ECHO™ program bridging MH training gaps for providers who serve rural communities in Guatemala. METHODS: The Project ECHO™ curriculum was implemented through a partnership between educational and nonprofit institutions in Guatemala City and the United States. Participants were primary care physicians and nurses working in rural Guatemala as well as medical/nursing/psychology students. Evaluation of its implementation was guided by a RE-AIM framework. Reach, effectiveness, adoption, fidelity, sustainability, acceptability, feasibility, and appropriateness were evaluated using a mixed-methods approach, using a pre-post survey and semi-structured focus groups. RESULTS: Forty unique participants attended the five sessions. Attitudes about mental health did not change quantitatively but self-efficacy improved in four of five modules. High quality fidelity scores were noted in two of five sessions. Sustainability scores across multiple domains were highly rated. Scores on instruments measuring acceptability, feasibility, and appropriateness were high. Focus groups showed two main themes: the curriculum filled a gap in education and further adaptation of the model might help improve the experience. CONCLUSION: Implementation of the Project ECHO™ educational model appeared to have good reach/adoption, showed improvements in self-efficacy, illuminated facilitators and barriers to sustainability, and was felt to be acceptable, feasible, and appropriate. Qualitative analysis supported these conclusions. Future directions would include ongoing evaluation and monitoring of further Project ECHO™ curricular experiences through this partnership and adaptation of this project to other learners and settings in Latin America.

The latent tuberculosis infection cascade of care during the COVID-19 pandemic response in a Mid-Sized US city.

Background: The COVID-19 pandemic response may unintentionally disrupt multiple public health services, including tuberculosis control programs. We aimed to assess differences in the cascade of care for latent tuberculosis infection (LTBI) in a Midwest U.S. city during the COVID-19 pandemic response. Methods: We conducted a retrospective cohort study of adult patients who presented for LTBI evaluation at the Hamilton County Public Health Tuberculosis Clinic in Ohio between 2019 and 2020. The pre-COVID-19 response period was defined as 01/2019 to 02/2020, and the COVID-19 pandemic response period (first wave) was defined as 04/2020 to 12/2020. We reviewed electronic medical records to extract sociodemographic information, medical history, follow-up and treatment data to define steps within the LTBI cascade of care. Logistic regressions were used to assess factors associated with LTBI treatment acceptance and completion, adjusted by potential confounders and COVID-19 period. Results: Data from 312 patients were included. There was a significant decrease in the number of monthly LTBI referrals (median, 18 vs. 8, p = 0.02) and LTBI evaluations (median, 17.5 vs. 7, p < 0.01) during the first wave of COVID-19. The proportion for whom immigration was listed as the indication for LTBI testing also declined (30% vs. 9%; p < 0.01) during COVID-19. More LTBI diagnoses were based on interferon-gamma release assay (IGRA; 30% vs. 49%; p < 0.01) during the COVID-19 response period. The proportion of people in the clinic for whom treatment for LTBI was recommended was similar before and during COVID-19 (76% vs. 81%, p = 0.41), as was LTBI treatment acceptance rates (56% vs. 64%, p = 0.28), and completion rates (65% vs. 63%, p = 0.85). In multivariate analysis, LTBI treatment acceptance was associated with Hispanic ethnicity, younger age, male sex, IGRA being used for diagnosis, and non-healthcare occupation, independent of COVID-19 period. LTBI treatment completion was associated with taking a rifamycin-containing regimen, independent of COVID-19 period. Conclusion: We observed a significant decline in the number of monthly LTBI referrals and evaluations during the first wave of COVID-19, revealing an unintended negative impact of the COVID-19 response in our region. However, LTBI treatment acceptance and completion rates were not affected during COVID-19.

Psychometric Properties of Scales Measuring Resilience in U.S. Latinx Populations: A Systematic Review.

Objectives: Instruments used to measure resilience have typically been developed in European or Anglosphere countries and emphasize personal factors of resilience. In addition to being a quickly growing ethnic minority group in the United States, Latinx individuals face unique stressors and protective factors that may contribute to resilience. This review sought to determine the extent to which instruments measuring resilience have been validated in U.S. Latinx populations and what domains of resilience those scales capture. Methods: A systematic literature review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards and included studies describing psychometric properties of resilience scales for Latinx individuals living in the United States. Articles were assessed for quality of psychometric validation; scales used in the final studies were assessed for representation of domains of the social ecological resilience model. Results: Nine studies were included in the final review examining eight separate resilience measures. The populations of these studies were heterogeneous geographically and demographically; more than half the studies only included Latinx populations as a subgroup. The breadth and quality of psychometric validation were variable across studies. The domains represented by the scales in the review most heavily assessed individual domains of resilience. Conclusion: The literature to date on psychometric validation of resilience measures in Latinx populations in the United States is limited and does not robustly capture aspects of resilience that may be particularly meaningful for Latinx populations, such as community or cultural factors. Instruments that are developed with and for Latinx populations are necessary to better understand and measure resilience in this population.

Underprepared: influences of U.S. medical students' self-assessed confidence in immigrant and refugee health care.

BACKGROUND: United States (U.S.) census data from 2017 indicates that the percentage of persons born outside of the U.S. is increasing. However, no studies describe the amount of class time focused on immigrant and refugee health during medical school in the U.S. nor on incoming residents' confidence in providing culturally sensitive care. The objective of this study is to characterize final-year medical students' exposure to immigrant and refugee health and their confidence in caring for these populations. METHODS: A voluntary, cross-sectional survey was sent electronically to fourth-year medical students at twelve U.S. medical schools in 2020, with 707 respondents (46% response rate). Questions addressed respondents' curricular exposure to immigrant and refugee health care during medical school and their confidence in providing culturally sensitive care. Chi-square tests were used to assess relationships between categorical variables, and odds ratios were calculated for dichotomized variables. RESULTS: Most students (70.6%) described insufficient class time dedicated to culturally sensitive care, and many (64.5%) reported insufficient clinical exposure in caring for immigrants/refugees. The odds that incoming residents felt 'usually' or 'always' confident in their ability to provide culturally sensitive care to immigrants and refugees were higher in those with more class time on culturally sensitive care (OR 5.2 [3.6-7.4]), those with more clinical opportunities to care for immigrants and refugees (OR 7.2 [5.1-10.2]), and those who participated in a domestic low-resource or international elective (OR 1.4 [1.02-1.9]). More than half (55.3%) of respondents reported feeling 'not at all' or only 'sometimes' confident in their ability to provide culturally sensitive care to immigrants/refugees. CONCLUSIONS: Most fourth-year U.S. medical students entering residency feel unprepared to deliver culturally sensitive care to immigrants and refugees. This may be mediated by increased exposure to didactic curricula class time and/or experiential clinical activities, as those factors are associated with improved student confidence.

A Systematic Literature Review of Community-Based Participatory Health Research with Sexual and Gender Minority Communities.

Purpose: The objective was to review sexual and gender minority (SGM) health research studies to gain an understanding of how the community-based participatory research (CBPR) framework has been operationalized. Methods: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to conduct a review of all SGM health research studies published in the past 10 years that cited a CBPR approach (PROSPERO Registration No. CRD42016036608). CINAHL, PubMed, and PsycINFO databases were systematically searched in October 2020. Dimensions of community involvement (e.g., shared decision-making; flexibility to community needs and priorities) and the strength of evidence for each dimension were rated using guidance from the Agency of Healthcare Research and Quality. Results: The 48 eligible articles identified reported a range of 0-11 (out of 13) community elements. Seven studies reported zero elements. Qualitative studies (n=28; 58.3%) had an average quality score of 2.32 (range: 1.43-2.5). The 15 (31.3%) cross-sectional studies had an average quality score of 2.08 (range: 1.64-2.27). Conclusion: Adhering to the CBPR framework is challenging. The benefits of striving toward its principles, however, can move us toward transformative and sustainable social change within SGM communities.

'Depression is not a familiar word': A mixed-methods approach to describe the experience of primary care nurses treating depression in rural Guatemala.

BACKGROUND: As the burden of mental health disorders continues to increase worldwide, there is significant need to describe the cultural variations in presentation, diagnosis and treatment of these diseases. An understanding of these variations can lead to the development of more effective programs to manage these conditions. In Guatemala, depression is the second-leading cause of disability and yet mental health treatment resources are scarce, particularly for indigenous individuals. AIMS: The primary research aim was to describe primary care nurses' explanatory models of depression in their clinical work in indigenous communities in Guatemala. A secondary research aim was to describe training and resources which would support and empower these nurses, in order to lessen risk for burnout. METHODS: A cross-sectional mixed methods survey was designed to elicit nurses' perspectives on the presentation, cause and treatment of depression in the communities they serve, as well as their clinical and emotional comfort in working with depressed individuals. Two subsequent focus groups gathered qualitative commentary which informed training and resource recommendations. Theoretical thematic analysis was used to generate codes and themes from focus group transcripts and survey responses. RESULTS: Guatemalan primary care nurses described symptoms of depression in their cultural context, identified socioeconomic factors which contribute to depression in their communities, and detailed treatment preferences. Limited referral options and concern for privacy made connecting patients to mental health care difficult. Nurses emphasized the need for community education on depression and for supplemental mental health resources which would increase their capacity to identify and treat depression. CONCLUSIONS: Primary care nurses in Guatemala identify and treat depression despite limited resources. Further investigations should focus on creating training modalities which include front-line nurses, given their critical role in the health system.

Training Mental Health Professionals in Gender-Affirming Care: A Survey of Experienced Clinicians.

Purpose: Transgender and gender nonconforming (TGNC) individuals have difficulty accessing mental health professionals (MHPs) prepared to deliver culturally informed care. This study aims to (1) explore the training experiences that had been available to MHPs who are actively providing care to TGNC individuals, (2) define which opportunities had been most beneficial in TGNC career development, and (3) determine the reasons MHPs sought training when it was absent in graduate curricula. Methods: A voluntary cross-sectional electronic survey was distributed through professional Listservs and public referral lists to interdisciplinary MHPs, who self-identified as having experience in providing care to TGNC individuals. Results: Two hundred eighty-one (n=281) counselors, marriage/family therapists, social workers, psychologists, psychiatrists, or psychiatric nurse practitioners responded to the survey. The two most common motivators for seeking training in gender-affirming care were filling a need in the community (68.8%) and having met a TGNC person in a clinical setting, who requested care (67.2%). Only 20.0% of our sample were exposed to relevant content in a graduate course, and 25.2% during clinical training. The most commonly available training opportunities were professional conferences (76.4%) and mentorship (41.2%). Respondents were most likely to recommend that others in their field be trained through structured clinical experience. Conclusion: This study identifies key strategies for graduate and post-graduate educators to better prepare MHPs to serve TGNC individuals. Wider availability of structured clinical experiences, didactic content delivered during graduate school or at professional conferences, and direct clinical mentorship will increase access to welcome and prepared mental health care providers for the TGNC population.

The impact of global health opportunities on residency selection.

BACKGROUND: An increasing number of medical trainees across specialties desire and expect Global Health (GH) experiences during training. It is useful for residency programs to know the impact that offering GH opportunities has on resident recruitment. The study objectives were to explore the importance of GH opportunities in residency selection among fourth-year medical students, examine the relationship between interest in GH and career plans, and describe students' perspectives on prior GH experiences. METHODS: The authors administered an electronic survey to all fourth-year medical students attending 12 different US institutions in February 2020. Data from the ten schools who were able to comply with the survey distribution methodology and with response rates above 25% were analyzed using descriptive statistics and Pearson's correlation. RESULTS: A total of 707 fourth-year medical students from the included schools completed the survey out of 1554 possible students (46% response rate). One third of respondents ranked the presence of GH experiences in residency as moderately or very important and 26% felt that the presence of a formal GH curriculum was at least moderately important, with variation noted among specialties. After training, 65% of students envision practicing internationally in some capacity. A desire to care for underserved patients in their careers was significantly correlated with an interest in GH experiences during residency. CONCLUSIONS: The opportunity to be involved in GH experiences during training can be an important factor for many medical students when considering residency choice, and the availability of these opportunities may be a valuable recruitment tool. Students valuing GH opportunities during residency are more interested in working with underserved populations in their future careers.

How Do We Measure Stress in Latinos in the United States? A Systematic Review.

Background: Previous research has documented that Latinos report higher levels of stress than other ethnicities and are an increasing portion of the demographics of the United States. While there are many measures to assess stress and other stress-related conditions, there are no systematic reviews to date to assess whether the current measures of generalized stress are valid or reliable in Latinos in the United States. The purpose of this systematic review was to examine the current state of the literature assessing the psychometric properties in stress measures in this population. Methods: We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to review the literature from January 1990 to May 2020 for studies, which measured the psychometric properties of scales measuring generalized stress in Latinos in the United States. Results: Twelve studies measured the psychometric properties of eight scales of generalized stress. The 10-item Perceived Stress Scale, the Hispanic Stress Inventory, the Hispanic Women's Social Stressor Scale, and the Family Obligation Stress Scale show the strongest reliability and validity for measuring stress in Latinos in the United States. Most studies were done in traditional immigration destinations in the United States. Conclusion: While four scales which show acceptable reliability and validity for measuring stress in Latinos in the United States, continuing to develop and further validate these scales within Latino communities will be critical to understand and address Latino stress more comprehensively. Our findings can inform health research and clinical interventions for this at-risk community.