What Parents Want Doctors to Know: Responses to an Open-Ended Item on an Asthma Questionnaire

ObjectiveUnstructured parental comments could solicit important information about children's asthma, yet are rarely captured in clinical asthma questionnaires. This mixed-methods study describes parents’ written responses to an open-ended question in a validated asthma questionnaire.MethodsThe Pediatric Asthma Control and Communication Instrument (PACCI) asthma questionnaire was administered to parents of children with asthma symptoms presenting to 48 pediatric primary care offices (PPCP), 1 pediatric pulmonology office, and 1 emergency department (ED). Responses to the question, “Please write down any concern or anything else you would like your doctor to know about your child's asthma” were analyzed using a phenomenological approach until thematic saturation was achieved for each site. Logistic regressions tested whether sociodemographic and clinical characteristics were associated with responding to the open-ended question.ResultsOf 7,988 parents who completed the PACCI, 954 (12%) responded to the open-ended question—2% in PPCP, 31% in the ED, and 50% in the pulmonary setting. More severe asthma was associated with higher odds of responding (odds ratio, 2.01; 95% confidence interval, 1.42–2.84). Based on responses provided, we identified 3 communication types: 1) clarifying symptoms, 2) asking questions, and 3) communicating distress. Responses also covered 5 asthma-related themes: 1) diagnostic uncertainty, 2) understanding asthma etiology and prognosis, 3) medication management, 4) impact on child function, and 5) personal asthma characteristics.ConclusionParents of children with severe asthma provided clarifying details, asked questions, and relayed health concerns and distress. None of these topics may be easily captured by closed-ended asthma questionnaires.     

Association of Parent Preventive Care with their Child's Recommended Well-Child Visits

BackgroundReceipt of recommended well-child care is lowest for children without insurance, many of whom receive care in community health centers (CHCs).ObjectiveTo understand if there is an association between parent preventive care and their children's well-child visits.MethodsWe used electronic health record data to identify children and link them to parents both seen in an OCHIN network (CHC; n = 363 clinics from 17 states), randomly selected a child aged 3 to 17 with ≥1 ambulatory visit between 2015 and 2018. We employed a retrospective, cohort study design and used general estimating equations Poisson regression to estimate yearly rates of well-child visits based on parent preventive care adjusted for relevant covariates and stratified by child age for 3 linked samples: mother only, father only, and two parents.ResultsWe included 75,398 linked mother only pairs, 12,438 in our father only, and 4,156 in our 2-parent sample. Children in the mother only sample had a 6% greater rate of yearly well-child visits when their mother received preventive care (adjusted rate ratio [ARR] = 1.06; 95% CI = 1.03–1.08) compared to no preventive care. Children in the father only sample had a 7% greater rate of yearly well-child visits when their father received preventive care (ARR = 1.07; 95% CI = 1.04–1.11) versus no preventive care. Children in the two parent sample had an 11% greater rate of yearly well-child visits when both parents received preventive care (ARR = 1.11; 95% CI = 1.03–1.19) compared to neither receiving preventive care.ConclusionsThese findings suggest focusing on receipt of healthcare for the whole family may improve well-child visit rates.     

Recruiting Rural Healthcare Providers Today: a Systematic Review of Training Program Success and Determinants of Geographic Choices

Background

Rural areas have historically struggled with shortages of healthcare providers; however, advanced communication technologies have transformed rural healthcare, and practice in underserved areas has been recognized as a policy priority. This systematic review aims to assess reasons for current providers’ geographic choices and the success of training programs aimed at increasing rural provider recruitment.

Methods

This systematic review (PROSPERO: CRD42015025403) searched seven databases for published and gray literature on the current cohort of US rural healthcare practitioners (2005 to March 2017). Two reviewers independently screened citations for inclusion; one reviewer extracted data and assessed risk of bias, with a senior systematic reviewer checking the data; quality of evidence was assessed using the GRADE approach.

Results

Of 7276 screened citations, we identified 31 studies exploring reasons for geographic choices and 24 studies documenting the impact of training programs. Growing up in a rural community is a key determinant and is consistently associated with choosing rural practice. Most existing studies assess physicians, and only a few are based on multivariate analyses that take competing and potentially correlated predictors into account. The success rate of placing providers-in-training in rural practice after graduation, on average, is 44% (range 20–84%; N = 31 programs). We did not identify program characteristics that are consistently associated with program success. Data are primarily based on rural tracks for medical residents.

Discussion

The review provides insight into the relative importance of demographic characteristics and motivational factors in determining which providers should be targeted to maximize return on recruitment efforts. Existing programs exposing students to rural practice during their training are promising but require further refining. Public policy must include a specific focus on the trajectory of the healthcare workforce and must consider alternative models of healthcare delivery that promote a more diverse, interdisciplinary combination of providers.

     

Caregiver outcomes of a dementia care program

The University of California, Los Angeles Alzheimer's and Dementia Care (ADC) program enrolls persons living with dementia (PLWD) and their family caregivers as dyads to work with nurse practitioner dementia care specialists to provide coordinated dementia care. At one year, despite disease progression, overall the PLWDs’ behavioral and depressive symptoms improved. In addition, at one-year, overall caregiver depression, strain, and distress related to behavioral symptoms also improved. However, not all dyads enrolled in the ADC program showed improvement in these outcomes. We conducted a mixed qualitative-quantitative study to explore why some participants did not benefit and what could be changed in this and other similar dementia management programs to increase the percentage who benefit. Semi-structured interviews (N=12) or surveys (N=41) were completed with 53 caregivers by telephone, mail and online. Seven areas for potential program improvement were identified from the first 12 interviews. These included: recommendations that did not match caregivers’ perceived care needs, barriers to accessing care and utilizing resources, differing care needs based on stage of dementia, needing services not offered by the ADC, needing more education or support, behavioral recommendations that the caregiver felt did not work, and poor rapport of the dementia expert with caregivers. Despite having been identified as having had no clinical benefit from participating in the program, most caregivers (85%) reported that the program was very beneficial or extremely beneficial. Respondents identified the close, longitudinal relationship and access to a dementia care expert as particularly beneficial. This dichotomy highlights that perceived benefit for most of the interviewed caregivers was not captured with the formal instruments used by the program.     

Intimate Partner Violence and Food Insecurity Predict Early Behavior Problems Among South African Children over 5-years Post-Birth

Households experiencing intimate partner violence (IPV) and food insecurity are at high risk of lifelong physical and behavioral difficulties. Longitudinal data from a perinatal home-visiting cluster-randomized controlled intervention trial in South Africa townships were used to examine the relationships between household settings and mothers’ histories of risk and children’s behavior problems at 3 and 5 years of age. IPV, food insecurity, maternal depressed mood, and geriatric pregnancy (at age of 35 or older) were consistently associated with children’s internalizing and externalizing behavior problems. Aggressive behavior was more prevalent among 3- and 5-year olds boys, and was associated with maternal alcohol use. The effects of these factors on child behavior were more prominent than maternal HIV status. There is a continuing need to reduce IPV and household food insecurity, as well as supporting older, depressed, alcohol using mothers in order to address children’s behavioral needs.

     

The role of disclosure & perceptions about providers in health discussions among gay and bisexual young men

ObjectivesGay and bisexual men may feel discomfort discussing sensitive topics such as sexual behaviors and substance use with their health providers, which may prevent them from receiving important health information. This study investigates whether patients’ perceptions of their provider’s sexual orientation predicts patient-provider discussions of sexual and general health topics, and whether this relationship is moderated by patients’ disclosure of sexual orientation to providers.MethodsData were collected online from a sample of 576 gay and bisexual men living in the USA, aged 18–26. Adjusted risk ratios were estimated by using modified Poisson regression with robust error variance.ResultsParticipants who believed their providers were gay or bisexual were more likely to have discussed sexual health topics, but not general health topics; simple slopes analyses revealed that this effect was stronger among those who had not disclosed to their providers. Disclosure was also consistently associated with increased likelihood of discussing almost all topics.ConclusionsFindings highlight differences in communication based on disclosure and perceived sexual orientation of provider, suggesting the need to further explore how these differences influence young gay and bisexual men’s health.Practice implicationsDyads may be more likely to discuss sexual health topics when patients believe their providers are sexual minorities themselves. In addition, patient-provider dyads may be likelier to discuss various health topics when providers are aware of patients’ sexual minority statuses.