Medical Students on the Virtual Front Line: A Literature Review Elective to Provide COVID-19 Clinical Teams With Essential Information

PROBLEM

At the Hackensack Meridian School of Medicine (HMSOM) in New Jersey, clinical activities for students were suspended on March 15, 2020, due to the COVID-19 pandemic. Clinical teams at Hackensack Meridian Health (HMH) needed resources for identifying and assimilating the medical literature regarding COVID-19, which was expanding and evolving daily. HMH leaders reached out to HMSOM leaders for assistance. The HMSOM leadership and faculty quickly organized a literature review elective.

APPROACH

Eight second-year medical students participated in a literature review elective course to research and synthesize the COVID-19 clinical literature to provide synopses of best practices for various clinical teams. By March 23, students were searching the literature and writing reports independently, mentored by a senior dean (an infectious diseases specialist) and supported by the associate dean of libraries and library team. The library team updated and categorized student reports daily on a website dedicated to the elective.

OUTCOMES

During the 6-week elective, 8 students produced 70 reports synthesizing the emerging COVID-19 literature to help answer practitioners' clinical questions in real time. One student report was posted on the American Academy of Ophthalmology website. All 70 were published online in Elsevier's health education faculty hub. On course evaluations, students expressed regret about not being directly involved in patient care but articulated their gratitude to be able to contribute to the clinical teams.

NEXT STEPS

In June 2020, the students returned to their clinical clerkships as COVID-19 clinical volumes declined and personal protective equipment became more available. Students continued to be available to the clinical teams to assist with COVID-19 questions. This literature review elective can serve as a model for other medical schools to use to deploy students to help synthesize the evolving literature on COVID-19 or other rapidly emerging research topics.

Model-Based Methods to Translate Adolescent Medicine Trials Network for HIV/AIDS Interventions Findings Into Policy Recommendations: Rationale and Protocol for a Modeling Core (ATN 161)

Background

The United States Centers for Disease Control and Prevention estimates that approximately 60,000 US youth are living with HIV. US youth living with HIV (YLWH) have poorer outcomes compared with adults, including lower rates of diagnosis, engagement, retention, and virologic suppression. With Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) support, new trials of youth-centered interventions to improve retention in care and medication adherence among YLWH are underway.

Objective

This study aimed to use a computer simulation model, the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-Adolescent Model, to evaluate selected ongoing and forthcoming ATN interventions to improve viral load suppression among YLWH and to define the benchmarks for uptake, effectiveness, durability of effect, and cost that will make these interventions clinically beneficial and cost-effective.

Methods

This protocol, ATN 161, establishes the ATN Modeling Core. The Modeling Core leverages extensive data—already collected by successfully completed National Institutes of Health–supported studies—to develop novel approaches for modeling critical components of HIV disease and care in YLWH. As new data emerge from ongoing ATN trials during the award period about the effectiveness of novel interventions, the CEPAC-Adolescent simulation model will serve as a flexible tool to project their long-term clinical impact and cost-effectiveness. The Modeling Core will derive model input parameters and create a model structure that reflects key aspects of HIV acquisition, progression, and treatment in YLWH. The ATN Modeling Core Steering Committee, with guidance from ATN leadership and scientific experts, will select and prioritize specific model-based analyses as well as provide feedback on derivation of model input parameters and model assumptions. Project-specific teams will help frame research questions for model-based analyses as well as provide feedback regarding project-specific inputs, results, sensitivity analyses, and policy conclusions.

Results

This project was funded as of September 2017.

Conclusions

The ATN Modeling Core will provide critical information to guide the scale-up of ATN interventions and the translation of ATN data into policy recommendations for YLWH in the United States.

Adolescent Trials Network for HIV-AIDS Scale It Up Program: Protocol for a Rational and Overview

BACKGROUND

The past 30 years have witnessed such significant progress in the prevention and treatment of HIV/AIDS that an AIDS-free generation and the end to the global AIDS epidemic are ambitious, but achievable, national and global goals. Despite growing optimism, globally, youth living with HIV are markedly less likely to receive antiretroviral therapy than adults (23% vs 38%). Furthermore, marked health disparities exist regarding HIV infection risk, with young men of color who have sex with men disproportionately affected. A large body of research has identified highly impactful facilitators of and barriers to behavior change. Several efficacious interventions have been created that decrease the rate of new HIV infections among youth and reduce morbidity among youth living with HIV. However, full benefits that should be possible based on the tools and interventions currently available are yet to be realized in youth, in large part, because efficacious interventions have not been implemented in real-world settings. Scale It Up (SIU) primarily aims to assemble research teams that will ultimately bring to practice evidence-based interventions that positively impact the youth HIV prevention and care cascades, and in turn, advance the fields of implementation science and self-management science.

OBJECTIVE

This paper aims to describe the structure of the U19-SIU and the effectiveness-implementation hybrid trials, as well as other center-wide protocols and initiatives, implemented within SIU.

METHODS

SIU will achieve its aims through 4 individual primary protocols, 2 center-wide protocols, and 3 cross-project initiatives.

RESULTS

SIU was funded by National Institute for Child Health and Human Development (U19HD089875) and began in October 2016. As of November 2018, 6 SIU protocols have launched at least the first phase of work (ATN 144 SMART: Sequential Multiple Assignment Randomized Trial; ATN 145 YMHP: Young Men's Health Project; ATN 146 TMI: Tailored Motivational Interviewing Intervention; ATN 153 EPIS: Exploration, Preparation, Implementation, Sustainment model; ATN 154 CM: Cascade Monitoring; ATN 156 We Test: Couples' Communication and HIV Testing). Further details can be found in the individual protocol papers.

CONCLUSIONS

To date, the youth HIV research portfolio has not adequately advanced the important care area of self-management. SIU protocols and initiatives address this broad issue by focusing on evaluating the effectiveness and implementation of self-management interventions. SIU is highly innovative for 5 primary reasons: (1) our research framework expands the application of "self-management"; (2) the 4 primary protocols utilize innovative hybrid designs; (3) our Analytic Core will conduct cost-effectiveness analyses of each intervention; (4) across all 4 primary protocols, our Implementation Science Core will apply implementation scales designed to assess inner and outer context factors; and (5) we shall advance understanding of the dynamics between provider and patient through analysis of recorded interactions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/11204.

Constructing tailored parental monitoring strategy profiles to predict adolescent disclosure and risk involvement

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Many parents use multiple monitoring strategies in different combinations over time to monitor their adolescents.

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Adolescents of parents who use multiple strategies reported greater risk involvement.

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Parents who solicited information only from adolescents had greater knowledge and adolescent disclosure.

Gender and generational influences on the pediatric workforce and practice

In response to demographic and other trends that may affect the future of the field of pediatrics, the Federation of Pediatric Organizations formed 4 working groups to participate in a year's worth of research and discussion preliminary to a Visioning Summit focusing on pediatric practice, research, and training over the next 2 decades. This article, prepared by members of the Gender and Generations Working Group, summarizes findings relevant to the 2 broad categories of demographic trends represented in the name of the group and explores the interface of these trends with advances in technology and social media and the impact this is likely to have on the field of pediatrics. Available data suggest that the trends in the proportions of men and women entering pediatrics are similar to those over the past few decades and that changes in the overall ratio of men and women will not substantially affect pediatric practice. However, although women may be as likely to succeed in academic medicine and research, fewer women than men enter research, thereby potentially decreasing the number of pediatric researchers as the proportion of women increases. Complex generational differences affect both the workforce and interactions in the workplace. Differences between the 4 generational groups comprising the pediatric workforce are likely to result in an evolution of the role of the pediatrician, particularly as it relates to aspects of work-life balance and the use of technology and social media.

Blocking the benefit of group-based HIV-prevention efforts during adolescence: the problem of HIV-related stigma

HIV-related stigma has been shown to impede HIV-antibody testing and safer sexual practices in adults. Less is known about its effects on prevention programs among at-risk youth. This study examined the longitudinal relationships between HIV-stigma and HIV-knowledge following completion of a validated group-based intervention. Data were provided by 1,654 African-American adolescents who participated in a large multi-city prevention trial (Project iMPACCS). Participants were randomly assigned to an empirically-validated skill-based intervention or a general health promotion control group. Both stigma and knowledge were assessed at baseline and post-intervention. Results suggested that adolescents participating in the intervention showed improvements in knowledge and decreases in stigma when compared to controls. Improvements in stigma appeared to be partly driven by improvements in knowledge. Higher baseline stigma was shown to reduce gains in knowledge in both the treatment and control groups. Results suggest that HIV-stigma can interfere with how youth identify with and internalize messages from group-based prevention trials.

Long term effects of community-based STI screening and mass media HIV prevention messages on sexual risk behaviors of African American adolescents

We examined the long-term effects of two interventions designed to reduce sexual risk behavior among African American adolescents. African American adolescents (N = 1383, ages 14-17) were recruited from community-based organizations over a period of 16 months in two northeastern and two southeastern mid-sized U.S. cities with high rates of sexually transmitted infection (STI). Participants were screened for three STIs (gonorrhea, chlamydia, and trichomoniasis) and completed an audio computer-assisted attitude, intention, and behavior self-interview. Youth who tested positive for an STI (8.3%) received treatment and risk reduction counseling. In addition, television and radio HIV-prevention messages were delivered during the recruitment period and 18 months of follow-up in one randomly selected city in each region. Analyses determined effects of the media program for those receiving a positive versus negative STI test result on number of sexual partners and occurrence of unprotected sex. Adolescents who tested STI-positive reduced their number of vaginal sex partners and the probability of unprotected sex over the first 6 months. However, in the absence of the mass media program, adolescents returned to their previously high levels of sexual risk behavior after 6 months. Adolescents who tested STI-positive and received the mass media program showed more stable reductions in unprotected sex. Community-based STI treatment and counseling can achieve significant, but short-lived reductions in sexual risk behavior among STI-positive youth. A culturally sensitive mass media program has the potential to achieve more stable reductions in sexual risk behavior and can help to optimize the effects of community-based STI screening.

Psychosocial Correlates of Dual Methods for Contraception and STI Protection in Urban Adolescents

Purpose. To identify correlates of combined hormonal contraception and condom use (dual method use) compared with no methods, condoms only or hormonal contraception only. Data are from a baseline assessment of 335 youth (52% female) enrolled in an intervention trial. Multinomial logistic regression identified theory-based factors associated with dual method use. At last intercourse 47% of respondents used dual methods, 29% condom only, 14% hormonal contraception only, and 10% no methods. No method users were less likely than dual-method users to feel “dirty” about pregnancy, to have ask about historical condom use, to have more than two partners, to view condom use as normative for boys and more likely to perceive pregnancy risk as remote. Hormonal-contraception-only users were more likely to have sex weekly and perceive sex as pleasurable for girls, and less likely to view condom use as normative for boys and to ask a partner to use a condom. Condom-only users were more likely to perceive pregnancy chance as remote, and less likely to have more than two partners and to want peers to think they were virgins. Interventions should include benefits of dual methods while counseling about the negative impact of STI and unplanned teen pregnancy.

Using culturally sensitive media messages to reduce HIV-associated sexual behavior in high-risk African American adolescents: results from a randomized trial

PURPOSE

To test the long-term effects of a mass media intervention that used culturally and developmentally appropriate messages to enhance human immunodeficiency virus (HIV)-preventive beliefs and behavior of high-risk African American adolescents.

METHODS

Television and radio messages were delivered for more than 3 years in two cities (Syracuse, NY; and Macon, GA) that were randomly selected within each of the two regionally matched city pairs, with the other cities (Providence, RI; and Columbia, SC) serving as controls. African American adolescents, aged 14-17 years (N = 1,710), recruited in the four cities over a 16-month period, completed audio computer-assisted self-interviews at recruitment and again at 3, 6, 12, and 18-months postrecruitment to assess the long-term effects of the media program. To identify the unique effects of the media intervention, youth who completed at least one follow-up and who did not test positive for any of the three sexually transmitted infections at recruitment or at 6-and 12-month follow-up were retained for analysis (N = 1,346).

RESULTS

The media intervention reached virtually all the adolescents in the trial and produced a range of effects including improved normative condom-use negotiation expectancies and increased sex refusal self-efficacy. Most importantly, older adolescents (aged 16-17 years) exposed to the media program showed a less risky age trajectory of unprotected sex than those in the nonmedia cities.

CONCLUSION

Culturally tailored mass media messages that are delivered consistently over time have the potential to reach a large audience of high-risk adolescents, to support changes in HIV-preventive beliefs, and to reduce HIV-associated risk behaviors among older youth.

The impact of community-based sexually transmitted infection screening results on sexual risk behaviors of African American adolescents

PURPOSE

To examine the effect of a community-based sexually transmitted infection (STI) screening program on sexual risk behavior among African American adolescents. We hypothesized that adolescents testing positive for an STI and receiving post-test counseling would reduce risky sexual practices, whereas STI-negative adolescents would show little or no change in protective sexual behavior after screening.

METHODS

From August 2006 to January 2008, we recruited 636 sexually active African American adolescents (age, 14-17) from community-based organizations in two mid-sized U.S. cities with high STI prevalence. Participants were screened for three STIs (gonorrhea, chlamydia, and trichomoniasis) and completed an audio computer-assisted self-interview. Youth who tested positive for an STI (6.6%) received treatment and counseling. Youth testing negative received no further intervention. Approximately 85% of participants completed 3- and 6-month follow-up assessments. Generalized estimating equations determined the effects of STI screening on adolescents' number of sexual partners and occurrence of unprotected sex.

RESULTS

Adolescents who tested positive for an STI reduced their number of vaginal and oral sex partners and the probability of unprotected sex. STI-negative adolescents demonstrated no change for numbers of partners or unprotected sex.

CONCLUSIONS

Community-based STI screening can help to reduce sexual risk behavior in youth who test positive for STIs. Alternative approaches will be needed to reduce risk behavior in youth who test negative but who are nevertheless at risk for acquiring an STI.

Mass media as an HIV-prevention strategy: using culturally sensitive messages to reduce HIV-associated sexual behavior of at-risk African American youth

The evidence base and theoretical frameworks for mass media HIV-prevention campaigns in the United States are not well-developed. We describe an intervention approach using culturally sensitive mass media messages to enhance protective beliefs and behavior of African American adolescents at risk for HIV. This approach exploits the potential that mass media messages have, not only to reach a large segment of the adolescent population and thereby support normative change, but also to engage the most vulnerable segments of this audience to reduce HIV-associated risk behaviors. The results from an ongoing HIV-prevention trial implemented in 2 medium-sized cities in the United States illustrate the effectiveness of this intervention approach.

Withdrawal (coitus interruptus) as a sexual risk reduction strategy: perspectives from African-American adolescents

This study examined adolescents' beliefs about the benefits and risks of withdrawal (coitus interruptus) with respect to both pregnancy and sexually transmitted infections (STIs). In the course of qualitative interviews with African-American youth aged 14-19 (n = 124) about sexuality and risk, 24 adolescents spontaneously introduced the subject of withdrawal as a sexual risk reduction strategy. Eighteen percent of the sexually experienced adolescents mentioned their own use of withdrawal as a contraceptive method. From adolescents' accounts of their own and their peers' use of withdrawal, we learned that the cultural meanings of withdrawal within the context of adolescent relationships were multifaceted. Using withdrawal could signal sexual prowess in male youth, was seen as promoting trust and caring within a stable relationship, and was seen as mitigating the risk of pregnancy. However, adolescents also recognized that withdrawal did not protect against most STIs. Beliefs about withdrawal as a gendered skill and as a sign of trust may undermine some adolescents' attempts to negotiate condom use for protection against STIs.

Condom failure: examining the objective and cultural meanings expressed in interviews with African American adolescents

The purpose of this study was to explore the meaning and context of self-reported "condom failure" among sexually active African American adolescents. Semistructured interviews regarding methods of protection from pregnancy and sexually transmitted disease (STD) with 124 youth (ages 14-19 years) were content analyzed. The findings suggested three meanings of condom failure. First, condom failure represents a legitimate and important risk related to sexual activity. Second, it can serve as an excuse repertoire for adolescents who engaged in unprotected sex and later experienced either pregnancy or a STD. Third, it may serve as an explanation for males who deceive their partners into having unprotected sex. The findings are discussed with regard to their implications for HIV or STD prevention and research.

Test-retest reliability of self-reported HIV/STD-related measures among African-American adolescents in four U.S. cities

PURPOSE

To evaluate the test-retest reliability of self-reported sexuality-related data in a sample of African American adolescents residing in four U.S. cities.

METHODS

Using audio computer-assisted self-interviewing (ACASI), 156 African American teens (mean age = 15.5 years) provided data on lifetime and recent sexual behavior, HIV/sexually transmitted disease (STD) testing, and theoretical antecedents of sexual risk behavior on two occasions separated by 2 weeks.

RESULTS

Most self-reports of lifetime sexual behavior and STD/HIV testing were stable across the two assessment points. Test-retest agreement was substantial for dichotomous indices of lifetime sexual behaviors and STD testing (kappas ranging from .61-.87), and for 3-month recall of vaginal sex (kappa = .72) and number of sexual partners (intraclass correlation coefficient [ICC] = .68). Lower reliability estimates emerged for count data of unprotected vaginal sex occasions (ICC = .44). Test-retest reliability estimates for antecedents of sexual risk behavior were highest for a validated measure of HIV-related knowledge (r = .73), but somewhat lower for peer norms (r = .58) and condom use self-efficacy (r = .50).

CONCLUSIONS

Although variability in the stability of self-report data was observed, findings confirm that most sexual behavior, STD and HIV testing history, and psychosocial measures can be assessed reliably among adolescents. Research should continue to identify strategies to enhance the reliability of self-report sexual behavior data from youth at risk for HIV and other sexually transmitted infections.

Part-time training in pediatric residency programs: principles and practices

Despite growing interest in part-time work, few pediatricians are pursuing part-time residency training. There is currently little guidance for programs or residents who wish to design an alternative path through residency. In this article we review the need for part-time residencies and address obstacles to be overcome in their initiation. Strategies are offered for residents and program directors planning part-time training pathways, with recommendations for implementation amid a changing environment for graduate medical education. The needs of trainees, residency programs, hospitals, and credentialing organizations are considered.

Protection Motivation Theory and Adolescent Drug Trafficking: Relationship Between Health Motivation and Longitudinal Risk Involvement

OBJECTIVE

To assess health protection motivation as explained by the constructs of protection motivation theory (PMT) and its association with drug trafficking over 2 years.

METHODS

The sample included 817 African American youth (13-16 years old) participating in an adolescent risk-reduction program. We developed an instrument measuring the level of health protection motivation (LHPM) using factor analysis. Changes in LHPM over time were examined among drug traffickers, abstainers, initiators, and nonrisk youths.

RESULTS

In sum, 151 participants reported selling and/or delivering drugs during the study period. The significant inverse correlation between drug-trafficking intention and health protection motivation was consistent with PMT. Changes in LHPM were strongly associated with the dynamics of behavior over 2 years.

CONCLUSIONS

Adolescent drug trafficking can be predicted by an overall level of health protection motivation. PMT and related theories should be considered in the design of drug-trafficking prevention intervention.

Influence of prior sexual risk experience on response to intervention targeting multiple risk behaviors among adolescents

PURPOSE

To identify correlates of sexual risk variations among African-American adolescents, and to examine the influence of prior sexual experience on response to a HIV risk-reduction intervention.

METHODS

Eight hundred seventeen African-American youth aged 13 to 16 years living in and around urban public housing in Baltimore were recruited to participate in a HIV risk-reduction intervention targeting multiple risk behaviors. An instrument designed to measure three levels of sexual risk ("abstinent," "protected sex" [having sex with a condom], and "unprotected sex" [having sex without a condom]) was administered at baseline, 6 months and 12 months postintervention. Multiple regression analyses were conducted to identify predictors of the degree of sexual risk using longitudinal data. Repeated measure analyses were conducted to assess behavioral changes over time among the three groups.

RESULTS

Data confirmed the co-variation of sexual risk behavior and other problem behaviors among adolescents, cross-sectionally and longitudinally. After exposure to an 8-session risk-reduction intervention, youth engaging in the highest degree of sexual risk demonstrated the greatest reduction in both sexual risk and other risks. These improvements were seen at both 6 months and 12 months postintervention. Youth who were abstinent at baseline maintained the lowest levels in risk involvement throughout the study period when compared with sexually active youth. However, abstinent youth risk involvement significantly increased at 6 months and 12 months after baseline. Youth engaging in protected sex at baseline demonstrated a significant increase in non-condom use and a significant decrease in multiple risk involvement over time.

CONCLUSIONS

Results support HIV risk-reduction intervention efforts that target multiple risk behaviors. Response of adolescents to the intervention is directly related to the sexual risk behavior at baseline. These data may suggest that the response to risk behavior intervention depends in part on the risk behavior profile of the population to which it is being applied.