Spanish-Speaking Caregiver Preferences for Social Determinants of Health Screening.

Equitable social determinants of health (SDOH) screening has been recommended by the Centers for Medicare & Medicaid Services and the Joint Commission; however, little is known about Spanish-speaking caregiver preferences on how they would like to be screened. We conducted a cross-sectional study at 3 pediatric clinics (October-December 2019). Caregivers completed (in English or Spanish) an SDOH screening preferences survey. Three hundred eighty-two of 443 caregivers approached (response rate = 86.2%) completed the survey. Most were female, preferred Spanish, and completed only high school. Spanish-speaking caregivers had greater odds of preferring verbal SDOH screening (odds ratio: 4.1; 95% confidence interval, 1.8-9.2) than English-speaking caregivers. Verbal SDOH screening should be a consideration in families who speak Spanish. Future studies should utilize qualitative methods to further explore Spanish-speaking caregiver preferences for SDOH screening.

Driving to Reduce Socioeconomic Barriers to Latent Tuberculosis Infection Care: A Mobile Pediatric Treatment Program.

CONTEXT: Tuberculosis (TB) disease causes significant morbidity, mortality, and public health impacts. Prevention of latent tuberculosis infection (LTBI) in children reduces the burden of disease. PROGRAM: The Texas Children's Mobile Clinic Program's (TC-MCP's) mission is to provide high-quality health care to underresourced children within the community setting. The TC-MCP serves a large foreign-born pediatric population. The need for an LTBI treatment program arose when caring for this high-risk population. IMPLEMENTATION: The TC-MCP providers collaborated with nationally recognized pediatric TB experts as well as local health departments that provide medications free of cost. The TC-MCP placed tuberculin skin tests (TSTs) on patients with risk factors for TB. TST-positive patients had an interferon-γ release assay (IGRA) performed. IGRA-positive patients had a chest radiograph (CXR) obtained. Children with positive IGRA and normal CXR were included in the LTBI program, which consisted of TC-MCP outpatient visits and 12 once-weekly doses of isoniazid/rifapentine (3HP) provided by local health departments. RESULTS: From January 2018 to March 2020, 785 TC-MCP patients received TSTs, of which 38 (4.8%) were positive. An additional 7 positive TSTs were identified from outside facilities. In addition to the 45 positive TSTs, 4 TC-MCP patients with follow-up difficulties had IGRAs done as the initial test. Of these 49 IGRAs done, 13 patients had a positive IGRA. An additional 6 patients with positive IGRAs from outside facilities were identified. Nineteen patients (36.5%) were diagnosed with LTBI; of whom, 18 completed 3HP therapy through the TC-MCP. Eighty-three percent (15/18) completed at least 2 in-person visits. DISCUSSION: Underresourced children at higher risk for TB benefit from a mobile clinic's unique reach. By utilizing community partnerships, mobile clinics can successfully fill gaps in the health care system where marginalized populations may be missed.

Distinct Risk Factors for Clinical and Bacteriologically Confirmed Tuberculosis among Child Household Contacts in a High-Burden Setting.

The identification and screening of children at high risk of tuberculosis is essential to the control and prevention of child tuberculosis (TB). BUTIMBA, an active case finding and household contact-tracing project implemented between 2013 and 2015 in Eswatini, evaluated 5,413 contacts of 1,568 index cases, of whom 82 (1.5%) were diagnosed with TB disease. We conducted univariate and multivariate clustered logistic regression analyses of risk factors for any TB diagnosis among child household contacts of TB cases. Children younger than 5 years and children with positive HIV status were more likely to have TB than children aged 5-14 years and children with negative HIV status, respectively (adjusted odds ratio [aOR]: 2.2, P < 0.001; aOR: 5.0, P < 0.001). Children with one or more TB symptoms were more likely to be diagnosed with TB based on clinical criteria, but less likely to have bacteriologically confirmed TB, highlighting subjectivity in determination of child TB.

Caregiver and Pediatric Health Care Provider Views on Social Needs Identification.

Background: The American Academy of Pediatrics recommends that pediatricians address the social determinants of health (SDOH) through research, community partnership, and policy development. Objective: This study aimed to identify the unmet SDOH of the patients served by the Pasadena-Pediatric and Adolescent Health Center (PA-PAHC) and to understand provider perspectives on screening for SDOH. Methods: The PA-PAHC is a low-income pediatric clinic in southeast Houston. A cross-sectional survey eliciting potential SDOH concerns was administered to caregivers of children presenting for their well-child exam, along with pediatric residents and staff/faculty. Staff/faculty and residents were asked about their perceptions of SDOH screening. Statistical analysis calculated frequencies for categorical data and mean/median for continuous variables. Secondary data analysis consisted of chi-square test and logistic regression. Results: A total of 110 caregivers, 22 residents, and 21 staff/faculty participated in the study. Caregivers listed health care access the most frequently (15.5%), followed by childcare, school, and immigration status as SDOH concerns. Residents (31.8%) and staff/faculty (23.8%) also identified health care access as a concern. When comparing topic selection by survey role, there was no statistically significant difference among the 3 groups (P = .257). Residents were more likely to indicate that screening was more time-consuming than were faculty/staff (P = .004). Conclusion: Staff/faculty and residents agree that SDOH affect child health and screening is valuable in the patient encounter. There were no differences in the needs identified by the 3 groups. Further evaluation to assess caregiver perspectives on standardized SDOH screening versus obtaining routine social history needs to be undertaken.

Challenges in Caring for Linguistic Minorities in the Pediatric Population.

Physicians in the United States (U.S.) face unique obstacles in providing care for persons with limited English proficiency (LEP), especially speakers of rare languages. Lack of professional resources is not a problem exclusive to health care delivery, with speakers of Mayan dialects receiving increasingly narrow representation in detention centers and immigration courts at the U.S.-Mexico border. Parent-child dynamics and other crucial information related to pediatric care may be lost in translation in the event of inadequate interpreter services. Several strategies could address disparities in medical care faced by persons with LEP, speaking rare as well as more common languages. These include increasing the availability of professional interpreters via expanded and/or incentivized training programs, providing focused education in interpreter services for medical students, and unifying interpretation services provided by local consulates and nonprofit agencies for both medical and legal purposes.

Reciprocity? International Preceptors' Perceptions of Global Health Elective Learners at African Sites.

BACKGROUND: Short-term global health electives (STGHEs) have become increasingly common, with evidence showing educational and clinical benefits for short-term learners (STLs). Despite increased recognition that STGHEs should be mutually beneficial for host sites and STLs, evidence demonstrating the impact on international host preceptors is lacking. OBJECTIVES: To understand international host preceptors' perceptions regarding benefits and burdens of hosting STLs. METHODS: Focus group discussions with a convenience sample of 10 of 18 eligible preceptors were conducted at pediatric STGHE sites in Malawi and Lesotho. Qualitative content analysis was performed to identify themes using a deductive-inductive approach. FINDINGS: Common themes regarding benefits to preceptors included increased knowledge and resources for learning from STLs, broadened differential diagnoses, and the satisfaction of teaching. Regarding burdens, preceptors perceived that supervising STLs decreases efficiency. Preceptors identified the burden of having to intervene in instances that could lead to patient harm. Some preceptors perceived that STLs under-valued preceptors' clinical decision-making in resource-limited contexts. CONCLUSIONS: Our findings emphasize the need for institutions to identify mutuality of benefits between STLs and host sites when developing STGHEs. Host preceptors identified robust pre-departure training for STLs, lengthened duration of STGHEs, and formal preceptor orientation as ways to enhance mutuality of benefits.

Reaching Uninsured Overweight and Obese Children Through the FitKids Mobile Lifestyle Modification Program: Lessons Learned.

The US prevalence of childhood obesity remains high with ~ 1 in five children diagnosed with obesity, and rates of obesity are likely higher in uninsured and Medicaid populations than in those with private insurance. To understand the impact of an obesity intervention, an established mobile clinic program conducted a study to determine whether a FitKids Mobile Lifestyle Modification Program could reach overweight and obese uninsured children. Eighty-six children (ages 8-18 years) participated in the FitKids study over two trial periods. The first trial consisted of four total visits, but subsequent visits after the initial visit had poor turnout. Through telephonic interviews, parents described positive aspects of the program: (1) providers' individual attention to their child, (2) increased knowledge about obesity, nutrition, and diet, (3) and parent and child were motivated to be more active. The most common barriers noted for return visits were (1) personal/family factors, (2) scheduling issues, and (3) distance to the clinic. As quality improvement, for the second trial, total number of visits was reduced from 4 to 3 visits and reminder calls were instituted. Percentage of children who returned for the third visit (67.5% for Trial 1 and 62.5% for Trial 2) was not improved despite quality improvement interventions. Mobile clinics provide a unique solution to reach underserved overweight and obese children to help them create a more active and healthy lifestyle, but more research is needed to understand how best to optimize programs.

Host clinical preceptors' perceptions of professionalism among learners completing global health electives.

OBJECTIVES: This study aims to gain an understanding of the perceptions of host clinical preceptors in Malawi and Lesotho of the professionalism exhibited by short-term learners from the United States and Canada during short-term global health electives. METHODS: Focus group discussions were conducted with 11 host clinical preceptors at two outpatient pediatric HIV clinics in sub-Saharan Africa (Malawi and Lesotho). These clinics host approximately 50 short-term global health learners from the United States and Canada each year. Focus group moderators used open-ended discussion guides to explore host clinical preceptors' perceptions of the professionalism of short-term global health learners. Thematic analysis with an inductive approach was used to identify salient themes from these focus group discussions. RESULTS: Eleven of the 18 possible respondents participated in two focus group discussions. Adaptability, eagerness to learn, active listening, gratitude, initiative, and punctuality was cited as professional behaviors among short-term global health learners. Cited unprofessional behaviors included disregard of local clinicians' expertise and unresponsiveness to feedback. Host clinical preceptors described difficulty providing feedback to short-term global health learners and discrepancies between what may be considered professional in their home setting versus in the study settings. Respondents requested pre-departure orientation for learners and their own orientation before hosting learners. CONCLUSIONS: Both host clinical preceptors and short-term global health learners should be aware that behaviors that may be considered best practice in one clinical setting may be perceived as unprofessional in another. Future studies to develop a common definition of professionalism during short-term global health electives are merited.

Perceptions and Expectations of Host Country Preceptors of Short-Term Learners at Four Clinical Sites in Sub-Saharan Africa.

OBJECTIVE: The demand for global health electives among medical students and residents has grown substantially, yet perspectives of international hosts are not well documented. This study aimed to assess how host country supervising clinical preceptors perceive learners on short-term global health electives of up to 6 weeks. METHODS: This study used a cross-sectional survey design and assessed international clinical preceptors' perceptions of short-term learners' (STLs) professional behaviors, medical knowledge, competency in systems-based care, as well as the benefits and burdens of hosting STLs. Surveys were sent to all clinical preceptors (n = 47) at 4 clinical sites in sub-Saharan Africa in 2015. RESULTS: Thirty-two preceptors (68%) responded to the survey. Most respondents (97%) were satisfied in their role hosting STLs and reported that STLs enhanced patient care and the professional image of the clinical site. Nearly half of respondents (45%) reported decreased self-perceived efficiency in clinical care tasks. Qualitative data identified concerns related to STLs' professionalism and teamwork. Respondents also identified knowledge gaps in understanding differences in health systems and epidemiology in host country settings. Respondents preferred that rotations last at least 4 weeks and that STLs complete predeparture training. CONCLUSIONS: STLs were largely positively regarded by international host clinical preceptors. To improve mutuality of benefits, sending institutions should ensure learners understand host country expectations of professionalism and that learners are well prepared for medical, ethical, and cultural challenges through participation in predeparture curricula that prepare them clinically and emotionally for these international experiences. Rotations of at least 4 weeks may enhance benefits to learners and hosts.

Implementing the Jadelle implant for women living with HIV in a resource-limited setting: concerns for drug interactions leading to unintended pregnancies.

An analysis of 570 HIV-infected women in Swaziland using the Jadelle implant showed that age, condom use, the provider who placed the implant, and CD4 cell count had no effect on unintentional pregnancy rates. Antiretroviral regimen at the time of pregnancy, however, correlated with pregnancy outcomes (P < 0.001). None of the women on nevirapine or lopinavir/ritonavir-based regimens (n = 208 and 13, respectively) became pregnant, whereas 15 women on efavirenz (n = 121; 12.4%) became pregnant.