Does Unconscious Bias Affect How Pediatricians Manage Their Patients?

BACKGROUND: Both implicit bias-referred to as unconscious bias-and explicit bias affect how clinicians manage patients. The Implicit Association Test (IAT) has incremental predictive validity relative to self-reports of unconscious bias. Few studies have uniquely specified the impact of unconscious bias in pediatric practices. OBJECTIVE: We aimed to assess the influence of unconscious bias on decision-making in the faculty in a pediatric academic center using the IAT, in addition to and separately applying clinical vignettes with racial and socioeconomic class associations in both tools as it relates to clinicians' race, gender, years in practice, education achieved by the clinician's parents, and language spoken. METHODS: We conducted a prospective quality control evaluation of faculty in an academic center's pediatrics department. An anonymous online tool was used to gather IAT responses, clinical vignette responses, demographics, and explicit bias questions. RESULTS: Of 295 faculty members (73% females), 230 completed the questionnaire, at least in part. Faculty reported on the explicit bias questions, neutral feelings when comparing the demands of educated vs noneducated patients, African American vs European American patients, and patients in the upper vs lower socioeconomic class. Of the approximately two-thirds who answered the IAT, faculty showed preference for European American and upper socioeconomic class. However, the clinical vignettes revealed no differences in how faculty responded to patients based on race or socioeconomic status when stratified by factors listed above, except physicians who favor upper socioeconomic class over lower socioeconomic class were more likely to give a detailed explanation of options if the patient's parent was upper socioeconomic class (P = 0.022). CONCLUSIONS: Pediatricians exhibit racial and socioeconomic unconscious bias that minimally affects decision-making, at least based on vignette responses.

Improving Immunization and Health Literacy Through a Community-Based Approach.

This report illustrates the importance of capacity-building to advance immunization literacy through a community-based participatory research (CPBR) approach to decrease child health immunization disparities. The research project utilizes culturally-tailored immunization and technology literacy modalities for dissemination in targeted low-income neighborhoods. The results suggest successful outcomes are dependent upon contributions and engagement of community members in all project processes, ensuring community buy-in and cultural relevance. The latter approach is time-intensive due in part to the need to build broad-based community partnerships, which can result in a promising approach to foster broader population impact.

Ancillary Benefit of Increased HPV Immunization Rates Following a CBPR Approach to Address Immunization Disparities in Younger Siblings.

Increasing HPV vaccination rates may decrease the disproportionately high HPV-associated disease incidence and mortality in African Americans (AA) and lower socioeconomic individuals. Data from a community-based participatory research (CBPR) study addressing immunization disparities among 19-35 month old children was analyzed to identify ancillary benefits in HPV immunization rates for adolescent siblings. Sub-study analysis inclusion criteria: AA (N = 118), 13-17 years old, younger sibling enrolled in parent study, and enrolled ≥ 9 months. Parent/caregiver interventions included: a web-based immunization toolkit with information on age-appropriate vaccines; a multimedia community outreach campaign; and reminder mailings. HPV up-to-date (UTD) status was defined as Wisconsin Immunization Registry (WIR) documentation of at least three HPV vaccines. McNemar's test compared pre/post intervention HPV status. Two dependent proportions testing compared the proportion of adolescents that became UTD in the study cohort, City of Milwaukee, and State of Wisconsin. Parents/caregivers perceived that 92% of adolescents were HPV-UTD, while only 24% had a WIR-verified HPV-UTD status. Baseline UTD status of the younger siblings 19-35 month old 4:3:1:3:3:1:4 antigen series was 63%, which increased to 86% at study completion. Adolescent's HPV-UTD immunization status increased from 30 (25%) at enrollment to 54 (46%) at study completion [p = 0.004]. A statistically significant larger proportion of adolescents became HPV-UTD in the study cohort (20%) compared to the City of Milwaukee [14%, p = 0.042] and the State of Wisconsin [14%, p = 0.046]. A culturally-tailored CBPR approach targeting parents/caregivers of younger AA children can have significant ancillary benefit to increase HPV immunization rates in adolescent siblings.

Workplace Lactation Support in Milwaukee County 5 Years After the Affordable Care Act.

BACKGROUND: Workplace lactation support has become increasingly important because returning to work is associated with discontinuing breastfeeding and women in the workforce are increasing. Research aim: This study examined workplace lactation support among Milwaukee County businesses 5 years after implementation of the Affordable Care Act's Break Time for Nursing Mothers provision. METHODS: A cross-sectional survey of Milwaukee County businesses was conducted in the summer of 2015 that inquired about workplace policies, lactation spaces, and other lactation resources offered. Business supports were stratified based on employer sizes: large (> 500 employees), medium (50-499 employees), and small (20-49 employees). A lactation amenity score was calculated for each business based on lactation resources available. RESULTS: Three hundred surveys were distributed and 71 businesses voluntarily completed the survey. Small employers were excluded from statistical analysis due to fewer responses ( n = 8). Overall, 87.3% ( n = 55) of respondents reported providing access to a multiuser space for lactation and 65.1% ( n = 41) reported providing a designated lactation space. Large employers ( n = 30) were more likely than medium employers ( n = 33) to provide a designated lactation space for breastfeeding or expressing (86.7% vs. 45.5%, p < .001). Large employers' mean amenity score was significantly higher than that of medium employers (3.37 vs. 2.57, p = .014), and they were also more likely to offer additional supports including access to a lactation consultant, classes, and materials (46.7% vs. 12.1%, p < .01). CONCLUSION: Large employers provide more lactation support than medium employers in Milwaukee County. All employers, regardless of size, need to increase additional lactation support for women in the workplace.

Evaluation of an oral health education session for Early Head Start home visitors.

OBJECTIVES: Home visiting programs promote the education and health of Early Head Start (EHS) children and pregnant women. However, EHS's oral health component is unevenly implemented. We conducted an educational intervention to improve oral health knowledge and motivational interviewing techniques among Wisconsin EHS home visitors. METHODS: A questionnaire assessing oral health-related knowledge and confidence was administered to home visitors before and after an educational session. Changes between pre/post-responses were analyzed with McNemar's test and Wilcoxon Signed Rank test. RESULTS: After the intervention there were increases in both knowledge and confidence related to oral health communication. Knowledge increases were observed in such topics as fluoridation, dental caries, and caregivers' role in assisting and supervising children's tooth brushing. CONCLUSIONS: A brief educational intervention was associated with increased home visitor knowledge and confidence in communicating oral health messages to EHS caregivers and pregnant women.

Improving Immunization Rates Through Community-Based Participatory Research: Community Health Improvement for Milwaukee's Children Program.

BACKGROUND: Nationally, immunization coverage for the DTaP/3HPV/1MMR/3HepB/3Hib/1VZV antigen series in children ages 19-35 months are near or above the Healthy People 2020 target (80%). However, children in lower socioeconomic families experience lower coverage rates. OBJECTIVE: Using a community-based participatory research (CBPR) approach, Community Health Improvement for Milwaukee Children (CHIMC) intervened to reduce disparities in childhood immunizations. METHODS: The CHIMC adopted a self-assessment to examine the effectiveness of adhering to CBPR principles. Using behavior change models, CHIMC implemented education, social marketing campaign, and theory of planned behavior interventions. Community residents and organizational representatives vetted all processes, messages, and data collection tools. RESULTS: Adherence to the principles of CBPR was consistently positive over the 8-year period. CHIMC enrolled 565 parents/caregivers with 1,533 children into educational and planned behavior change (PBC) interventions, and enrolled another 406 surveyed for the social marketing campaign. Retention rate was high (80%) with participants being predominately Black females (90%) and the unemployed (64%); children's median age was 6.2 years. Increased knowledge about immunizations was consistently observed among parents/caregivers. Social marketing data revealed high recognition (85%) of the community-developed message ("Take Control: Protect Your Child with Immunizations"). Barriers and facilitators to immunize children revealed protective factors positively correlated with up-to-date (UTD) status (p<0.007). Ultimately, children between the ages of 19 and 35 months whose parents/caregivers completed education sessions and benefitted from a community-wide social marketing message increased their immunization status from 45% baseline to 82% over 4 years. CONCLUSIONS: Using multilayered interventions, CHIMC contributed to the elimination of immunization disparities in children. A culturally tailored CBPR approach is effective to eliminate immunization disparities.

Assessment of Food Insecurity in Children's Hospital of Wisconsin's Emergency Department.

IMPORTANCE: Food insecurity is associated with adverse health outcomes and the emergency department may be an ideal location to identify food insecure children and families. OBJECTIVE: To determine the prevalence of food insecurity in families with children that present to an urban pediatric emergency department (ED) in Milwaukee, Wisconsin. DESIGN: We conducted a cross-sectional survey of caregivers of children 0-18 years between June and August, 2013. The questionnaire included 2 validated statements about food insecurity and demographic and community resource questions. Participant rooms were approached during predefined shifts in an order determined by random number generation. OUTCOMES: The primary outcome was the prevalence of caregivers who identified as food insecure. A secondary outcome was the percentage of food insecure caregivers who accessed community resources. RESULTS: We enrolled 309 caregivers; 141 (45.6%) reported food insecurity. Nearly 60% (56.8%) of nonwhite caregivers were food insecure compared to 27.4% of non-Hispanic white caregivers (P < 0.0001). Among caregivers who identified as food insecure, 82% reported using at least 1 community resource for food. CONCLUSIONS: Almost half of caregivers presenting to the ED reported food insecurity. The ED is an excellent location for targeted intervention to identify and link food insecure families with community resources.

Factors Associated With Increased Reading Frequency in Children Exposed to Reach Out and Read.

OBJECTIVE: A 2014 American Academy of Pediatrics Policy Statement on Literacy Promotion recommends providers endorse daily caregiver-child reading during health supervision visits. Reach Out and Read (ROR) is a widely used model of office-based early literacy promotion. We hypothesized that exposure to ROR and other variables such as reading as part of a bedtime routine positively correlate with caregiver-child reading frequency. METHODS: This is a cross-sectional study based on a convenience sample of caregivers at 8 ROR-Milwaukee sites, which serve predominantly low-income populations in Milwaukee. On the basis of results of previously validated questionnaires, odds ratios were calculated to determine which variables are significantly associated with caregivers' reading to children 0 to 2 (rarely), 3 to 6 (often), and 7 (daily) days per week. Random forest analysis was performed to examine relative importance of variables in predicting caregivers' reading frequency. RESULTS: A total of 256 caregivers were eligible for analysis; those who reported receiving ≥4 books from pediatricians read to children more days per week compared to those receiving fewer books (5.07 vs 3.61, P < .001) and were more likely to read daily (odds ratio 3.07, 95% confidence interval 1.80-5.23). Caregivers' interest in reading, number of children's books in the home, reading as part of a bedtime routine, and number of books received from pediatricians were among the most important variables in distinguishing rarely, often, and daily reading caregivers. CONCLUSIONS: Exposure to ROR-Milwaukee's intervention is associated with increased reading frequency. Identified variables such as reading as a bedtime routine and number of children's books in the home should be targets for future literacy-promoting interventions.

Evaluation of a social marketing campaign to increase awareness of immunizations for urban low-income children.

OBJECTIVE: To assess community awareness of childhood immunizations and intent to immunize children after a social marketing immunization campaign. METHODS: We used 2 interviewer-assisted street-intercept surveys to evaluate awareness of childhood immunizations and intent to immunize low-income children. The "Take Control! Immunize" social marketing campaign was developed using a community-based participatory research approach and used billboards, flyers, and various "walking billboard" (eg, backpacks, pens) to deliver immunization messages in the community settings. RESULTS: Over 85% of community members recalled the "Take Control! Immunize" message. Almost half of those who saw the immunization message indicated that the message motivated them to act, including getting their children immunized or calling their physician to inquire about their children's immunizations status. All respondents indicated that immunizations were important for children and that they were likely or very likely to immunize their children. Respondents who reported that "Take Control!" messages motivated them to act in the first intercept survey were significantly more likely than those in the second intercept to report being likely or very likely to immunize their children. CONCLUSION: Culturally appropriate social marketing immunization messages in targeted urban settings can increase parental awareness and behavioral intention to immunize children.

Conquering racial disparities in perinatal outcomes.

Infant mortality rate (IMR) is a reference indicator for societal health status. Trend analysis of IMR highlights 2 challenges to overcome in the United States: (1) US IMR is higher than most industrialized countries and (2) there are persistent racial/ethnic disparities in birth outcomes, especially for blacks. Racial/ethnic infant mortality disparities result from the complex interplay of adverse social, economic, and environmental exposures. In this article, racial/ethnic disparities are discussed, highlighting trends, the role of epigenetics in understanding mechanisms, key domains of community action planning, and programs and policies addressing the racial gaps in adverse birth outcomes.

Residency training and use of strategies to promote community child health one year after graduation.

OBJECTIVE: Training pediatricians to understand child health in the context of community and to develop skills to engage with community organizations remain priorities for residency education in the United States. Our objectives were to: 1) determine use of strategies to influence community child health by graduates of the Community Pediatrics Training Initiative (CPTI); and 2) to identify personal, practice, and residency program factors associated with use of strategies 1 year after residency. METHODS: Analysis of data from the Dyson Initiative National Evaluation included surveys of physicians ("graduates") 1 year after residency and surveys of CPTI program leaders. Graduates reported personal and practice characteristics and use of one or more strategies to influence community child health. Chi-square and logistic regression were used to examine associations between personal, practice, and programmatic factors with use of strategies. RESULTS: Of the 511 graduates (68% participation), 44% reported use of one or more strategies. After adjusting for residency site, time spent in general pediatrics, and program emphasis on individual level advocacy, we found that graduates were more likely to report using strategies if they felt responsible for improving community child health (adjusted odds ratio [aOR] 4.1, 95% confidence interval [95% CI] 2.5-6.9), had contact with a person who provides guidance about community pediatrics (aOR 1.8, CI 1.2-2.6), or trained in a program that places great emphasis on teaching population level advocacy skills (aOR 2.3, CI 1.3-4.2). CONCLUSIONS: Personal perspectives and residency education influence community involvement, even early in pediatricians' careers. Efforts are needed to understand how content and delivery of training influence community engagement over time.

Field methods for discovering practical wisdom: the microdynamics of going beyond technical rationality in real-world practice.

Practical wisdom is essential to occupational and professional practice. However, the emphasis on technical rationality in these domains neglects the necessity of practical wisdom in doing specialized, skilled work. Microdynamic methods for analyzing social action enabled the discovery and examination of practical wisdom in two interactional episodes from community health work. Practical wisdom was found in specific acts: in adaptation to and interpretation of logical forces and interactional rules of these acts; and in deliberation among choices to reach intended outcomes. Cultivating skills in microdynamic methods for finding and analyzing practical wisdom is an essential tool for practitioners and organizations.

Early literacy interventions: reach out and read.

Linkages between literacy attainment and poverty have been well documented in the literature. This article reviews the literacy challenges for low-income children and the need for child health practitioners to be informed about children's literacy environments. The authors define literacy and emphasize that literacy is a continuous developmental process that includes listening, speaking, reading, and writing. Read Out and Read is a national model that has demonstrated its effectiveness to improve receptive and expressive language development in children. Pediatricians are uniquely positioned to address early child's literacy development because they are often the only practitioner regularly encountering parents, infants, and children during the preschool years.

Pediatric residents address critical child health issues in the community.

BACKGROUND: Practicing pediatricians are challenged to look beyond the clinical settings for local resources to address health threats to children and families. Pediatric residents' perceptions of the realities faced by families that they frequently see in the emergency room and outpatient or inpatient units are inadequate. OBJECTIVES: The Community Pediatrics Training Initiative (CPTI) is a national initiative within the American Academy of Pediatrics designed to prepare future pediatricians to serve families from traditionally underserved communities. The three unique components of this CPTI at Children's Hospital of Wisconsin (CHW) and the Medical College of Wisconsin (MCW) support child health improvement through (1) interactive discussions with families, (2) exposure to programs in community agencies, and (3) community initiatives. METHODS: Pediatric residents, along with community partners, have implemented more than 25 community initiatives in the areas of access to care, adolescent health, child advocacy, and environmental and public health. RESULTS: The immediate assessment from our CPTI curriculum demonstrates community experiences significantly promote their competencies in child advocacy and system-based practice while expanding their knowledge of the impact of poverty. In 2005, a survey of 84 postgraduates (75% response rate) assessed the effectiveness of community pediatrics training. All graduates self-reported that they are moderately to greatly prepared to respond to children's culture, age, gender, and disabilities. Of the 43 (68%) graduates who are currently in practice, 10 (23%) are working directly with underserved populations. CONCLUSIONS: The development of community initiatives by pediatric residents in partnership with community stakeholders greatly expanded residents' competencies in child health improvement.

Pediatric residents' perceptions of community involvement prior to residency.

OBJECTIVES: To describe baseline perceptions of first-year pediatric residents of participating in community activities, to determine whether demographic factors are related to perceived benefits and constraints, and to identify factors associated with expected community involvement. METHODS: Pediatric residents beginning their training in the fall of 2000 to 2003 participated in a 12-item self-administered written survey as part of the national evaluation of the Dyson Community Pediatrics Training Initiative. RESULTS: Of the 612 first-year residents surveyed (90% response rate), most reported they receive personal satisfaction (92%) and gain valuable skills and knowledge (83%) from their involvement in community activities. Less than a quarter felt peer support and professional recognition were benefits. Almost two thirds reported logistics and lost personal time as constraints to community involvement. Compared with their colleagues, older residents (> 29 years) and underrepresented minority residents reported fewer constraints. Most residents (72%) expect moderate to substantial involvement in community activities after graduating. Those expecting greater involvement were more likely to report personal satisfaction, gaining valuable skills and knowledge, peer support, and the opportunity to spend time with like-minded peers as benefits. CONCLUSIONS: Pediatric residents beginning their postgraduate training perceive numerous benefits from their participation in community activities and most expect a moderate degree of future community involvement. Residency directors should: 1) consider their trainees' insights from prior community involvement and 2) integrate meaningful community experiences in ways that confront logistic barriers and time constraints.