Social Determinants of Health in a Kansas Community Health Center.

Introduction: This study explored the connection between social determinants and patient self-rated health at Health Ministries Clinic (HMC) in a rural Kansas community. Community health centers, like HMC, strive to deliver comprehensive care that addresses patients' social needs. Methods: The authors employed a convenience sampling method to survey HMC patients with appointments from September to December 2018. The authors analyzed the data using Chi-square tests and descriptive statistics in RStudio, considering p <0.05 as significant. Results: Among 200 patient responses, education, income, employment, and insurance status were negatively correlated with self-rated health. Notably, 86.2% of college or graduate school graduates reported positive health ratings, compared to 40% of those who did not finish high school (χ2(12, N = 185) = 25.75, p = 0.012). Lower income individuals (income <$34,000 per year) consistently rated their health poorer than their higher income counterparts (χ2(12, N = 174) = 23.96, p = 0.021). Patients without insurance or with public insurance (Medicaid/ CHIP) perceived their health as worse than those on private health insurance and Medicare (χ2(12, N = 137) = 35.67, p <0.001). Conclusions: Our findings suggest that low educational attainment, income, and lack of health insurance are associated with barriers to healthcare, resulting in poor health outcomes and chronic disease among those with lower socioeconomic status. This underscores the strong association between social determinants and self-rated health among HMC patients. These results can be used by other clinics to assess the needs of their patient population and enhance community health initiatives.

Development of a Continuous Glucose Monitoring Service by Clinical Pharmacists in a Medically Underserved Population.

Background: Continuous glucose monitoring (CGM) is an evolving technology that provides a wealth of information to aid in managing diabetes. Professional CGM (ProCGM) is recommended when personal CGM is not desired or available. Patients in medically underserved areas may have limited access to personal CGM devices, thus ProCGM devices can be used for short-term monitoring and medication adjustment. Clinical pharmacists are well-positioned to help set up and establish personal and professional CGM management services. Objectives: To determine the effect of ProCGM in patients with persistently uncontrolled type 2 diabetes in a medically underserved population (MUP). Methods: Pre-post intervention analysis of a single cohort of patients in a public health center. Patients with persistently uncontrolled (A1c > 9%) and taking at least one daily dose of insulin were included. Included participants wore a ProCGM sensor and met with the clinical pharmacist at least once for ProCGM data interpretation and education. The primary analysis evaluated patients who achieved an A1c <9% 1-6 months after intervention. The change in A1c was also evaluated. Participants completed a pre- and post-survey about their experience. Results: Twenty-two patients were included in the final analysis. Ten patients achieved an A1c <9% (45%). The mean A1c pre- and post-ProCGM was 11.0% and 9.8% respectively, with a decrease of -1.2% (p=0.055) overall and a decrease of -1.7% for patients who wore the sensor for at least 10 days (p=0.012; n=15). Using the CGM data 91% of participants had a change to their medication regimen and 45% achieved an A1c <9%. Six participants experienced hypoglycemia per the CGM report, but only two were aware of it. After reviewing their glucose report with the pharmacist, 95% of the respondents agreed or strongly agreed to feeling more knowledgeable about blood sugar patterns after reviewing the report with a pharmacist. Conclusion: Almost half of the patients in the study achieved an A1c <9%. This study demonstrated glycemic benefit in patients in a MUP who wore a ProCGM for at least 10 days and met with a clinical pharmacist. Data from ProCGM enabled patients to better understand glucose patterns in those with persistently uncontrolled type 2 diabetes.

Feasibility of regional center telehealth visits utilizing a rural research network in people with Parkinson's disease.

Background: Impaired motor and cognitive function can make travel cumbersome for People with Parkinson's disease (PwPD). Over 50% of PwPD cared for at the University of Arkansas for Medical Sciences (UAMS) Movement Disorders Clinic reside over 30 miles from Little Rock. Improving access to clinical care for PwPD is needed. Objective: To explore the feasibility of remote clinic-to-clinic telehealth research visits for evaluation of multi-modal function in PwPD. Methods: PwPD residing within 30 miles of a UAMS Regional health center were enrolled and clinic-to-clinic telehealth visits were performed. Motor and non-motor disease assessments were administered and quantified. Results were compared to participants who performed at-home telehealth visits using the same protocols during the height of the COVID pandemic. Results: Compared to the at-home telehealth visit group (n = 50), the participants from regional centers (n = 13) had similar age and disease duration, but greater disease severity with higher total Unified Parkinson's disease rating scale scores (Z = -2.218, p = 0.027) and lower Montreal Cognitive Assessment scores (Z = -3.350, p < 0.001). Regional center participants had lower incomes (Pearson's chi = 21.3, p < 0.001), higher costs to attend visits (Pearson's chi = 16.1, p = 0.003), and lived in more socioeconomically disadvantaged neighborhoods (Z = -3.120, p = 0.002). Prior research participation was lower in the regional center group (Pearson's chi = 4.5, p = 0.034) but both groups indicated interest in future research participation. Conclusions: Regional center research visits in PwPD in medically underserved areas are feasible and could help improve access to care and research participation in these traditionally underrepresented populations.

Presencia de egresados y egresadas de la Universidad Nacional del Sur en el sistema de residencias médicas de Bahía Blanca / Presence of graduates from the National University of the Sur in the medical residency system of Bahía Blanca

Introducción: La atracción, captación y retención son determinantes de una distribución equitativa de profesionales de la salud. Objetivo: describir las decisiones de formación de posgrado de egresados/as de medicina de la Universidad Nacional del Sur (UNS), y su impacto en el sistema de residencias médicas de Bahía Blanca durante el año 2023. Resultados: el 79,63% de quienes egresaron de esta universidad decidieron realizar una residencia médica, y el 51,12 % adjudicó en especialidades del Primer Nivel de Atención con una adjudicación en pediatría menor a la media nacional. La carrera de medicina local cubrió el 39,24 % de las vacantes de Bahía Blanca, y el 38% de sus graduados/as decidió formarse en otras ciudades. Ocho residencias de la ciudad quedaron sin ingresantes en el 2023. Conclusión: existe una gran proporción de egresados/as de la UNS que eligen especialidades de APS. Hay una baja adjudicación en Pediatría que contrasta con la elección de Medicina Familiar, a diferencia de las elecciones a nivel nacional. En términos generales hay un déficit en la atracción y captación de egresados/as de la UNS por parte del sistema de salud local, lo cual demanda a los sectores docentes y asistenciales nuevas estrategias para captar y atraer profesionales en área prioritarias (AU)

Introduction: Attraction, recruitment and retention are determinants of an equitable distribution of healthcare professionals. Objective: to describe the postgraduate training decisions of medical graduates from the National University of the South (UNS), and their impact on the Bahía Blanca medical residency system during the year 2023. Results: 79.63% of Those who graduated from this university decided to carry out medical residency, and 51.12% were awarded in First Level Care specialties with a pediatric award lower than the national average. The local medical career covered 39.24% of the vacancies in Bahía Blanca, and 38% of its graduates decided to train in other cities. Eight residences in the city were left without entrants in 2023. Conclusion: there is a large proportion of UNS graduates who choose APS specialties. There is a low allocation in Pediatrics that contrasts with the choice of Family Medicine, unlike the elections at the national level. In general terms, there is a deficit in the attraction and recruitment of UNS graduates by the local health system, which demands new strategies from the teaching and healthcare sectors to attract and attract professionals in priority areas (AU)

Medical deserts in Spain-Insights from an international project.

INTRODUCTION: Medical deserts are a growing phenomenon across many European countries. They are usually defined as (i) rural areas, (ii) underserved areas or (iii) by applying a measure of distance/time to a facility or a combination of the three characteristics. The objective was to define medical deserts in Spain as well as map their driving factors and approaches to mitigate them. METHODS: A mixed methods approach was applied following the project "A Roadmap out of medical deserts into supportive health workforce initiatives and policies" work plan. It included the following elements: (i) a scoping literature review; (ii) a questionnaire survey; (iii) national stakeholders' workshop; (iv) a descriptive case study on medical deserts in Spain. RESULTS: Medical deserts in Spain exist in the form of mostly rural areas with limited access to health care. The main challenge in their identification and monitoring is local data availability. Diversity of both factors contributing to medical deserts and solutions applied to eliminate or mitigate them can be identified in Spain. They can be related to demand for or supply of health care services. More national data, analyses and/or initiatives seem to be focused on the health care supply dimension. CONCLUSIONS: Addressing medical deserts in Spain requires a comprehensive and multidimensional approach. Effective policies are needed to address both the medical staff education and planning system, working conditions, as well as more intersectoral approach to the population health management.

Exploring Medical Career Choice to Better Inform Swiss Physician Workforce Planning: Protocol for a National Cohort Study.

BACKGROUND: A medical student's career choice directly influences the physician workforce shortage and the misdistribution of resources. First, individual and contextual factors related to career choice have been evaluated separately, but their interaction over time is unclear. Second, actual career choice, reasons for this choice, and the influence of national political strategies are currently unknown in Switzerland. OBJECTIVE: The overall objective of this study is to better understand the process of Swiss medical students' career choice and to predict this choice. Our specific aims will be to examine the predominately static (ie, sociodemographic and personality traits) and predominately dynamic (ie, learning context perceptions, anxiety state, motivation, and motives for career choice) variables that predict the career choice of Swiss medical school students, as well as their interaction, and to examine the evolution of Swiss medical students' career choice and their ultimate career path, including an international comparison with French medical students. METHODS: The Swiss Medical Career Choice study is a national, multi-institution, and longitudinal study in which all medical students at all medical schools in Switzerland are eligible to participate. Data will be collected over 4 years for 4 cohorts of medical students using questionnaires in years 4 and 6. We will perform a follow-up during postgraduate training year 2 for medical graduates between 2018 and 2022. We will compare the different Swiss medical schools and a French medical school (the University of Strasbourg Faculty of Medicine). We will also examine the effect of new medical master's programs in terms of career choice and location of practice. For aim 2, in collaboration with the Swiss Institute for Medical Education, we will implement a national career choice tracking system and identify the final career choice of 2 cohorts of medical students who graduated from 4 Swiss medical schools from 2010 to 2012. We will also develop a model to predict their final career choice. Data analysis will be conducted using inferential statistics, and machine learning approaches will be used to refine the predictive model. RESULTS: This study was funded by the Swiss National Science Foundation in January 2023. Recruitment began in May 2023. Data analysis will begin after the completion of the first cohort data collection. CONCLUSIONS: Our research will inform national stakeholders and medical schools on the prediction of students' future career choice and on key aspects of physician workforce planning. We will identify targeted actions that may be implemented during medical school and may ultimately influence career choice and encourage the correct number of physicians in the right specialties to fulfill the needs of currently underserved regions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53138.

Implementing the European code of cancer practice in rural settings.

Existing evidence often indicates higher cancer incidence and mortality rates, later diagnosis, lower screening uptake and poorer long-term survival for people living in rural compared to more urbanised areas. Despite wide inequities and variation in cancer care and outcomes across Europe, much of the scientific literature explicitly exploring the impact of rurality on cancer continues to come from Australia and North America. The European Code of Cancer Practice or "The Code" is a citizen and patient-centred statement of the most salient requirements for good clinical cancer practice and has been extensively co-produced by cancer patients, cancer professionals and patient advocates. It contains 10 key overarching Rights that a cancer patient should expect from their healthcare system, regardless of where they live and has been strongly endorsed by professional and patient cancer organisations as well as the European Commission. In this article, we use these 10 fundamental Rights as a framework to argue that (i) the issues and needs identified in The Code are generally more profound for rural people with cancer; (ii) addressing these issues is also more challenging in rural contexts; (iii) interventions and support must explicitly account for the unique needs of rural residents living with and affected by cancer and (iv) new innovative approaches are urgently required to successfully overcome the challenges faced by rural people with cancer and their caregivers. Despite equitable healthcare being a key European policy focus, the needs of rural people living with cancer have largely been neglected.

Increased Organizational Stress in Primary Care: Understanding the Impact of the COVID-19 Pandemic, Medicaid Expansion, and Practice Ownership.

BACKGROUND: Primary care is the foundation of health care, resulting in longer lives and improved equity. Primary care was the frontline of the COVID-19 pandemic public response and essential for access to care. Yet primary care faces substantial structural and systemic challenges. As part of a longitudinal analysis to track the capacity and health of primary care, we surveyed every primary care practice in Virginia in 2018 and again in 2022. METHODS: Surveys were emailed or mailed up to 6 times and nonresponders received a phone call. Questions assessed organizational characteristics, scope of care, capacity, and organizational stress in the prior year. From respondents, 39 clinicians, nurses, staff, administrators, and practice managers were interviewed. RESULTS: 526 out of 2296 primary care practices (23% response rate) completed the survey, with broad representation across geography, ownership, and payer mix. Compared with 2018, in 2022 there were increases in practices owned by health systems (25% vs 43%, P < .0001) and average percent of patients with Medicaid per practice (12% vs 22%, P < .0001). The percent of practices reporting any major stressor increased from 34% to 53% (P < .0001). The main increased stress was losing a clinician, with 13% of practices in 2018 versus 42% in 2022 reporting losing a clinician (P < .0001). CONCLUSIONS: Primary care practices are resilient and continue to serve their communities, including a broad scope of services and care for underserved people. However, the COVID-19 pandemic caused significant stress. With an increase in clinicians leaving clinical practice, we anticipate worsening access to primary care.

Virtual Music Therapy for Substance Use Disorders in a Federally Qualified Health Center.

BACKGROUND: Music therapy (MT) is an effective adjunctive treatment for substance use disorders (SUD), which is primarily available in inpatient treatment centers and rarely provided in outpatient primary care. METHODS: We evaluated the feasibility and acceptability of a virtual group MT program for SUD in a Federally Qualified Health Center (FQHC), and secondarily assessed patient perceptions of its effect. Feasibility was measured by implementation-related process measures, attendance and use of technology. Qualitative interviews eliciting participant perceptions were conducted to evaluate acceptability and effect. Mood scores, substance use and craving were measured before and after the intervention. RESULTS: Onboarding of the music therapist took 3.5 months. All MT sessions were attended by 1 to 5 individuals out of 6. Participants reported that group MT was "soothing" and "calming," gave them tools to treat cravings and stress, and created a sense of community. They reported that during sessions their cravings decreased. Anxiety and depression scores trended down, as did the number of days of substance use. They all stated they would seek out MT again. DISCUSSION: Our results suggest that remote group MT is feasible and acceptable to our FQHC patients with SUD. Patients reported an improvement in mood and their ability to manage stress, and a decrease in substance use. CONCLUSION: We wish to build on the results of this study to enhance our understanding of the effects of MT in the outpatient setting, and broaden our patients' access to MT in primary care.

Developing a 'Living with Cancer' programme in a rural and coastal setting: Experiences of collaborative and innovative co-production across an Integrated Health System.

INTRODUCTION: With projected increases in cancer prevalence, and demonstrated unmet need, there is an urgency for a collaborative approach to improving the lives of those living with cancer particularly in rural and coastal areas where cancer survivors face unique challenges. We report on an innovative 'Living with Cancer' (LWC) programme in the rural and coastal English county of Lincolnshire. METHODS: In 2016, the Lincolnshire LWC programme was established to develop person-centred, local support for people living with cancer, their carers and significant others in Lincolnshire. This article reports on the setup of the LWC programme, our innovative approach to delivering cancer care in a rural and coastal setting, as well as our most salient achievements. RESULTS: This work, developed within a policy context of tackling health inequalities and personalised approaches to care, started with stakeholder and community engagement where people described the challenges to living well after cancer and the need to focus on 8 themes further exacerbated by rurality. Recognising the limitations of conventional approaches, led to the development of a strategy underpinned by a shared set of principles and a philosophy of the importance of a transformative, whole-system, place-based, asset-based, and person-centred approaches. The strategy is now being coordinated and delivered across all cancer pathways and Lincolnshire communities. In 2022, permanent funding was secured, and our success was also demonstrated by a national Macmillan Integration Excellence award. DISCUSSION: The initial success of the LWC programme in Lincolnshire is a result of an explicit focus on 'transformation' rather than 'improvement', and a programme not solely situated in an acute setting, which needed a whole systems approach with a focus on person-centred support and community engagement.

Joint exposure to urban-rural status and medically underserved area residence and risk of severe COVID-19 outcomes in 2020.

INTRODUCTION: The purpose of this study is to estimate the risk of severe COVID-19 among individuals residing in rural, medically underserved counties compared to those living in other counties. METHODS: Individual-level COVID-19 hospitalization and death data and demographic variables were downloaded from the Centers for Disease Control and Prevention. The 2013 National Center for Health Statistics Urban-Rural Classification Scheme was used to classify urban and rural counties. Health Resources and Services Administration's medically underserved area (MUA) designation was used to identify underserved counties. County-level data were drawn from the 2015-2019 American Community Survey 5-year estimates. Analytic samples included data from Minnesota and Montana in 2020. Urban-rural/MUA joint exposure categories were created: rural/MUA, rural/non-MUA, urban/MUA, urban/non-MUA. Hierarchical logistic regression models estimated associations (odds ratios and 95% confidence intervals (CI)) between rurality, MUA status, joint urban-rural/MUA status, and severe COVID-19, overall and stratified by age and state. Models were adjusted for individual- and county-level demographics. RESULTS: The odds of severe outcomes among those living in rural counties were 13% lower (95%CI: 0.83-0.91) than those in urban counties. The odds of severe outcomes among those living in MUA counties were 24% higher (95%CI: 1.18-1.30) than those in non-MUA counties. For joint exposure analyses, the odds of severe outcomes were highest among those living in urban/MUA counties compared to those in rural/non-MUA counties (adjusted odds ratio: 1.36, 95%CI: 1.27-1.44). CONCLUSION: In 2020, the risk of severe COVID-19 was more pronounced in urban counties and underserved areas. Results highlight the need for locality-based public health recommendations that account for rural and underserved areas and may inform future pandemic preparedness by identifying counties most in need of resources and education at various stages of the pandemic.

Evaluating the impact of a child sponsorship programme on paediatric health and development in Calauan, Philippines: A retrospective audit.

AIM: International child sponsorship programmes comprise a considerable proportion of global aid accessible to the general population. Team Philippines (TP), a health care and welfare initiative run in association with the University of Notre Dame Sydney since 2013, leads a holistic sponsorship programme for 30 children from Calauan, Philippines. To date, empirical research has not been performed into the overall success and impact of the TP child sponsorship programme. As such, this study aims to evaluate its effectiveness in improving paediatric outcomes. METHODS: Study cohorts comprised 30 sponsored and 29 age- and gender-matched non-sponsored children. Data were extracted from the TP Medical Director database and life-style questionnaires for July-November 2019. Outcome measures included anthropometry, markers of medical health, dental health, exercise, and diet. Statistical analyses were performed in SPSS. RESULTS: Sponsorship resulted in fewer medical diagnoses and prescription medications, superior dental health, and improved diet. Further, sponsored children may show a clinically significant trend towards improved physical health. Sponsorship did not affect growth and development metrics, or levels of physical activity. CONCLUSIONS: The TP child sponsorship programme significantly impacts positive paediatric health outcomes in the Calauan community. The strength of the programme lies in its holistic, sustainable, and community-based model, which is enabled by effective international child sponsorship. This study further supports the relationship between supporting early livelihood and improved health in the paediatric population.

Engagement, Satisfaction, and Mental Health Outcomes Across Different Residential Subgroup Users of a Digital Mental Health Relational Agent: Exploratory Single-Arm Study.

BACKGROUND: Mental illness is a pervasive worldwide public health issue. Residentially vulnerable populations, such as those living in rural medically underserved areas (MUAs) or mental health provider shortage areas (MHPSAs), face unique access barriers to mental health care. Despite the growth of digital mental health interventions using relational agent technology, little is known about their use patterns, efficacy, and favorability among residentially vulnerable populations. OBJECTIVE: This study aimed to explore differences in app use, therapeutic alliance, mental health outcomes, and satisfaction across residential subgroups (metropolitan, nonmetropolitan, or rural), MUAs (yes or no), and MHPSAs (yes or no) among users of a smartphone-based, digital mental health intervention, Woebot LIFE (WB-LIFE). WB-LIFE was designed to help users better understand and manage their moods and features a relational agent, Woebot, that converses through text-based messages. METHODS: We used an exploratory study that examined data from 255 adults enrolled in an 8-week, single-arm trial of WB-LIFE. Analyses compared levels of app use and therapeutic alliance total scores as well as subscales (goal, task, and bond), mental health outcomes (depressive and anxiety symptoms, stress, resilience, and burnout), and program satisfaction across residential subgroups. RESULTS: Few study participants resided in nonmetropolitan (25/255, 10%) or rural (3/255, 1%) areas, precluding estimates across this variable. Despite a largely metropolitan sample, nearly 39% (99/255) resided in an MUA and 55% (141/255) in an MHPSA. There were no significant differences in app use or satisfaction by MUA or MHPSA status. There also were no differences in depressive symptoms, anxiety, stress, resilience, or burnout, with the exception of MUA participants having higher baseline depressive symptoms among those starting in the moderate range or higher (Patient Health Questionnaire-8 item scale≥10) than non-MUA participants (mean 16.50 vs 14.41, respectively; P=.01). Although working alliance scores did not differ by MHPSA status, those who resided in an MUA had higher goal (2-tailed t203.47=2.21; P=.03), and bond (t203.47=1.94; P=.05) scores at day 3 (t192.98=2.15; P=.03), and higher goal scores at week 8 (t186.19=2.28; P=.02) as compared with those not living in an MUA. CONCLUSIONS: Despite the study not recruiting many participants from rural or nonmetropolitan populations, sizable proportions resided in an MUA or an MHPSA. Analyses revealed few differences in app use, therapeutic alliance, mental health outcomes (including baseline levels), or satisfaction across MUA or MHPSA status over the 8-week study. Findings suggest that vulnerable residential populations may benefit from using digital agent-guided cognitive behavioral therapy. TRIAL REGISTRATION: ClinicalTrials.gov NCT05672745; https://clinicaltrials.gov/study/NCT05672745.

New-onset dyslipidemia in adult cancer survivors from medically underserved areas: a 10-year retrospective cohort study.

BACKGROUND: Cancer survival rates are increasing; however, studies on dyslipidemia as a comorbidity of cancer are limited. For efficient management of the disease burden, this study aimed to understand new-onset dyslipidemia in medically underserved areas (MUA) among cancer survivors > 19 years. METHODS: This study used 11-year (2009-2019) data from the Korean National Health Insurance Service sample cohort. Cancer survivors for five years or more (diagnosed with ICD-10 codes 'C00-C97') > 19 years were matched for sex, age, cancer type, and survival years using a 1:1 ratio with propensity scores. New-onset dyslipidemia outpatients based on MUA were analyzed using the Cox proportional hazards model. RESULTS: Of the 5,736 cancer survivors included in the study, the number of new-onset dyslipidemia patients was 855 in MUA and 781 in non-MUA. Cancer survivors for five years or more from MUA had a 1.22-fold higher risk of onset of dyslipidemia (95% CI = 1.10-1.34) than patients from non-MUA. The prominent factors for the risk of dyslipidemia in MUA include women, age ≥ 80 years, high income, disability, complications, and fifth-year cancer survivors. CONCLUSIONS: Cancer survivors for five years or more from MUA had a higher risk of new-onset dyslipidemia than those from non-MUA. Thus, cancer survivors for five years or more living in MUA require healthcare to prevent and alleviate dyslipidemia.

Patient and Clinician Sociodemographics and Sexual History Screening at a Multisite Federally Qualified Health Center: A Mixed Methods Study.

PURPOSE: In 2018, there were 68 million sexually transmitted infections in the United States. Sexual history screening is an evidence-based practice endorsed by guidelines to identify risk of these infections and adverse sexual health outcomes. In this mixed methods study, we investigated patient- and clinician-level characteristics associated with receipt of sexual history screening, and contextualized these differences in more depth. METHODS: We collected sociodemographics of patients from the electronic health record and sociodemographics of their primary care clinicians via a census survey. Semistructured interviews were conducted with key practice staff. We conducted multilevel crossed random effects logistic regression analysis and thematic analysis on quantitative and qualitative data, respectively. RESULTS: A total of 53,246 patients and 56 clinicians from 13 clinical sites participated. Less than one-half (42.4%) of the patients had any sexual history screening documented in their health record. Patients had significantly higher odds of documented screening if they were gay or lesbian (OR = 1.23), were cisgender women (OR = 1.10), or had clinicians who were cisgender women (OR = 1.80). Conversely, patients' odds of documented screening fell significantly with age (OR per year = 0.99) and with the number of patients their clinicians had on their panels (OR per patient = 0.99), and their odds were significantly lower if their primary language was not English (OR = 0.91). In interviews, key staff expressed discomfort discussing sexual health and noted assumptions about patients who are older, in long-term relationships, or from other cultures. Discordance of patient-clinician gender and patients' sexual orientation were also noted as barriers. CONCLUSIONS: Interventions are needed to address the interplay between the social and contextual factors identified in this study, especially those that elicited discomfort, and the implementation of sexual history screening.

Impact of Service-Based Student Loan Repayment Program on the Primary Care Workforce.

PURPOSE: As the average level of medical education indebtedness rises, physicians look to programs such as Public Service Loan Forgiveness (PSLF) and National Health Service Corps (NHSC) to manage debt burden. Both represent service-dependent loan repayment programs, but the requirements and program outcomes diverge, and assessing the relative uptake of each program may help to inform health workforce policy decisions. We sought to describe variation in the composition of repayment program participant groups and measure relative impact on patient access to care. METHODS: In this bivariate analysis, we analyzed data from 10,677 respondents to the American Board of Family Medicine's National Graduate Survey to study differences in loan repayment program uptake as well as the unique participant demographics, scope of practice, and likelihood of practicing with a medically underserved or rural population in each program cohort. RESULTS: The rate of PSLF uptake tripled between 2016 and 2020, from 7% to 22% of early career family physicians, while NHSC uptake remained static at 4% to 5%. Family physicians reporting NHSC assistance were more likely than those reporting PSLF assistance to come from underrepresented groups, demonstrated a broader scope of practice, and were more likely to practice in rural areas (23.3% vs 10.8%) or whole-county Health Professional Shortage Areas (12.5% vs 3.7%) and with medically underserved populations (82.2% vs 24.2%). CONCLUSIONS: Although PSLF supports family physicians intending to work in public service, their peers who choose NHSC are much more likely to work in underserved settings. Our findings may prompt a review of the goals of service loan forgiveness programs with potential to better serve health workforce needs.

Educational Strategies to Reduce Physician Shortages in Underserved Areas: A Systematic Review.

The shortage of physicians in rural and underserved areas is an obstacle to the implementation of Universal Health Coverage (UHC). We carried out a systematic review to analyze the effectiveness of initiatives in medical education aimed to increase the supply of physicians in rural or underserved areas. We searched for studies published between 1999 and 2019 in six databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Interventional or observational controlled studies were defined as inclusion criteria. A total of 955 relevant unique records were selected for inclusion, which resulted in the identification of 17 articles for analysis. The admission of students from rural areas associated with a rural curriculum represented 52.95% of the interventions. Medical practice after graduation in rural or underserved areas was the most evaluated outcome, representing 12 publications (70.59%). Participants of these educational initiatives were more likely to work in rural or underserved areas or to choose family medicine, with significant differences between the groups in 82.35% of the studies. Educational strategies in undergraduate and medical residencies are effective. However, it is necessary to expand these interventions to ensure the supply of physicians in rural or urban underserved areas.

Update on Pediatric Mild Traumatic Brain Injury in Rural and Underserved Regions: A Global Perspective.

BACKGROUND: Mild traumatic brain injury (MTBI) causes morbidity and disability worldwide. Pediatric patients are uniquely vulnerable due to developmental and psychosocial factors. Reduced healthcare access in rural/underserved communities impair management and outcome. A knowledge update relevant to current gaps in care is critically needed to develop targeted solutions. METHODS: The National Library of Medicine PubMed database was queried using comprehensive search terms (("mild traumatic brain injury" or "concussion") and ("rural" or "low-income" or "underserved") and ("pediatric" or "child/children")) in the title, abstract, and Medical Subject Headings through December 2022. Fifteen articles on rural/underserved pediatric MTBI/concussion not covered in prior reviews were examined and organized into four topical categories: epidemiology, care practices, socioeconomic factors, and telehealth. RESULTS: Incidences are higher for Individuals in rural regions, minorities, and those aged 0-4 years compared to their counterparts, and are increasing over time. Rural healthcare utilization rates generally exceed urban rates, and favor emergency departments (vs. primary care) for initial injury assessment. Management guidelines require customization to resource-constrained settings for implementation and adoption. Decreased community recognition of the seriousness of injury is a consensus challenge to care provision by clinicians. Low parental education and income were correlated with decreased MTBI knowledge and worse outcome. Telehealth protocols for triage/consultation and rehabilitation were feasible in improving care delivery to rural and remote settings. CONCLUSIONS: Pediatric MTBI/concussion patients in rural/underserved regions experience increased risks of injury, geographic and financial healthcare barriers, and poorer outcomes. Globally, under-reporting of injury has hindered epidemiological understanding. Ongoing MTBI education should be implemented for rural caregivers, schools, and low-income populations to improve community awareness. Telehealth can improve care delivery across acuity settings, and warrants judicious inclusion in triage and treatment protocols.

Perceived Impact of a Core Rotation on Hawai'i Island on Future Career Intentions among Obstetrics and Gynecology Residents.

Hawai'i Island faces a growing shortage of obstetric and gynecology providers. Increased exposure of obstetrics and gynecology residents to rural rotations during their core training may increase their interest in rural practice after graduation. In an effort to address the health care needs of women on Hawai'i Island, the University of Hawai'i Obstetrics and Gynecology Residency Program established a 4-week required gynecology rotation in the town of Hilo. Between July 2019 and June 2020, third- and fourth-year obstetrics and gynecology residents provided outpatient gynecologic care and participated in gynecologic surgeries at Hilo-based medical facilities. A total of 9 residents participated in this Hilo-based rotation. This retrospective study extracted data from post-rotation evaluations. Eight out of 9 participating residents (89%) felt that the rotation slightly or far exceeded their expectations. After the rotation, 7 residents (78%) reported an interest in practicing in a rural community, while only 3 residents (33%) reported having this interest prior to the rotation. Underserved rural areas seeking to recruit and retain obstetrics and gynecology physicians may benefit from partnering with residency training programs.

Recruitment and retention of general practitioners in European medical deserts: a systematic review.

INTRODUCTION: Despite policies aiming at universal health coverage by ensuring availability and accessibility of general practitioners (GPs), medically underserved areas are still present in Europe. This systematic review aims to summarize and compare literature on interventions and their potential effectiveness of GP recruitment and retention in these underserved areas ('medical deserts') from 2011 onwards. METHODS: PubMed and Embase were used to identify publications, applying a two-stage selection process. All types of study designs, published in the past 10 years, were included if they discussed a possible intervention for GP recruitment or retention covering an underserved area in an EU-27/EEA/EFTA country (part of the European Union, the European Economic Area or the European Free Trade Association). Exclusion criteria were abstracts or full text not available, conference abstracts, poster presentations, books or overlapping secondary literature. Identified interventions were classified into four categories: 'education', 'professional and personal support', 'financial incentives' and 'regulation'. Eligible articles were critically appraisal by two authors (JB, LF), independently, by using the Joanna Briggs Institute checklist. RESULTS: Of the 294 publications initially retrieved, 25 publications were included. Of them, 14 (56%) described educational interventions, 13 (52%) professional and personal support, and 11 (40%) financial or regulatory interventions. Overlapping categories were often described (56%). The effectiveness of educational or supportive interventions has mainly been evaluated cross-sectionally, whereby causal inference on future GP availability cannot be implied. Few and mixed results were found for the effectiveness of financial and regulatory interventions, because period co-interventions were not taken into account during the study. CONCLUSION: In the past 10 years, educational and supportive interventions to improve GP recruitment and retention have been reported most frequently, but often overlapping strategies are seen. While multiple strategies have potential to be effective, their limited evaluation makes it difficult to provide suggestions for policymakers to adapt their GP recruitment and retention strategies aiming at a best-practice approach in European medical deserts.