Upholding Our PROMISE: Underrepresented in Medicine Pediatric Residents' Perspectives on Interventions to Promote Belonging

PURPOSE

Underrepresented in medicine (UIM) residents experience challenges during training that threaten their sense of belonging in medicine; therefore, residency programs should intentionally implement interventions to promote belonging. This study explored UIM pediatric residents' perspectives on current residency program measures designed to achieve this goal.

METHOD

The authors conducted a secondary qualitative analysis as part of a national cross-sectional study, PROmoting Med-ed Insight into Supportive Environments (PROMISE), which explored pediatric residents' experiences and perspectives during training in relation to their self-identities. A 23-item web-based survey was distributed through the Association of Pediatric Program Directors Longitudinal Educational Research Assessment Network from October 2020 to January 2021. Participants provided free-text responses to the question "What are current measures that promote a sense of belonging for the UIM community in your training program?" The authors used conventional content analysis to code and identify themes in responses from UIM participants.

RESULTS

Of the 1,748 residents invited to participate, 931 (53%) residents from 29 programs completed the survey, with 167 (18%) identifying as UIM. Of the 167 UIM residents, 74 (44%) residents from 22 programs responded to the free-text question. The authors coded more than 140 unique free-text responses and identified 7 major themes: (1) critical mass of UIM residents; (2) focused recruitment of UIM residents; (3) social support, including opportunities to build community among UIM residents; (4) mentorship; (5) caring and responsive leadership; (6) education on health disparities, diversity, equity, inclusion, and antiracism; and (7) opportunities to serve, including giving back to the local community and near-peer mentorship of UIM premedical and medical students.

CONCLUSIONS

This is the first national study to describe UIM pediatric residents' perspectives on interventions that promote a sense of belonging. Programs should consider implementing these interventions to foster inclusion and belonging among UIM trainees.

Physical Activity Counseling and Documentation by Pediatric Residents in Primary Care: Before and After Introduction of the FITT Principle

Physician training on physical activity (PA) counseling in patient care is highly variable. The objective of this study was to improve PA counseling by pediatric residents through introduction of the four components of PA, called the FITT principle (frequency, intensity, time, type). Pediatric residents (n=30) received lectures, curriculum content, and an electronic smart-phrase addressing PA in obesity, including the FITT principle. Surveys assessed resident attitudes, and chart reviews (n = 423 over 16 months) identified evidence of PA counseling including FITT principle components preintervention and postintervention. Survey results showed positive attitudes and confidence regarding primary care provider roles in counseling on PA, with no differences postintervention. Chart reviews demonstrated increased documentation on PA frequency postintervention (pre 31.9% vs post 50.9%, P=.00006), but no significant changes in intensity, time or type. In conclusion, a focused PA curriculum promoted PA counseling by pediatric residents, with increased documentation of one component of the FITT principle.

Nutrition Services and Resources for Families in the First 1000 Days: A Needs Assessment in the State of California

Objectives

To identify the current status of and gaps within nutrition services and resources provided to California families during the first 1000 days of life (from conception to age 2 years).

Methods

A semi-structured online survey was developed by a task-force group at the University of California, Irvine, and Dairy Council of California. The survey addressed five pillars of nutrition service provision in the first 1000 days: accessibility of services, delivery of nutrition education, content of nutrition messages, breastfeeding support, and professional development on nutrition. The survey was disseminated across California to health professionals and providers from agencies that provide services to pregnant women and families with infants and young children up to 2 years of age.

Results

148 survey responses were obtained with representation across the state and organization types (37% healthcare, 23% childcare/preschools, 20% Government agencies, and 20% community organizations). Almost 60% of respondents estimated that at least 75% of the clients they serve are Medi-Cal eligible. Although most organizations provide referrals to the Women Infants and Children program, only 46% of clinical and 69% of community-based respondents reported referring clients to the CalFresh benefits program. Several needs were identified to better support optimal health, growth and development including improved access to nutritious food and educational resources for low-income families, improved cultural appropriateness in the delivery and content of nutrition education, messaging around key micronutrients for fetal and early child development, enhanced social support and guidance regarding breastfeeding, and further professional development opportunities on early life nutrition. Notably, technology as a means of outreach and communicating nutritional messages to families during the first 1000 days was reportedly underutilized.

Conclusions

The accessibility, content, and delivery of nutritious food, nutrition-related resources, and breastfeeding support for families in the first 1000 days can be improved. A comprehensive and coordinated approach to improve social support, nutrition security and education is needed to support health outcomes during the first 1000 days of life.

Funding Sources

NIH National Center for Advancing Translational Sciences.

Variations in Maternal Factors and Preterm Birth Risk among Non-Hispanic Black, White, and Mixed-Race Black/White Women in the United States, 2017

OBJECTIVE

This study aims to compare preterm birth (PTB) risk and maternal factors associated with PTB among non-Hispanic White, Black, and mixed-race Black/White women in the United States.

METHODS

In this study, we used U.S. birth certificate data from the 2017 National Vital Statistics System. We included live singleton births to women who self-identified as non-Hispanic White, Black, or mixed-race Black/White. PTB was defined as less than 37 weeks of gestation. We used logistic regression models to estimate the PTB odds ratios for Black and Black/White relative to White women, adjusted for maternal factors. We used logistic regression to estimate associations between PTB and maternal factors in race-stratified models.

RESULTS

The sample included a total of 2,297,076 births in 2017 to White (n = 1,792,257), Black (n = 476,969), and Black/White (n = 27,850) women. The prevalence of PTB varied for Black (11.2%), Black/White (8.2%), and White (6.8%) women. The odds of PTB compared with White differed for Black (odds ratio, 1.51; 95% confidence interval, 1.49-1.53) and Black/White (odds ratio, 1.13; 95% confidence interval, 1.08-1.18) women after adjusting for maternal factors. The odds of PTB associated with maternal sociodemographic, prepregnancy, and gestational factors differed by maternal race.

CONCLUSIONS

Evaluation of PTB risk among White, Black, and Black/White women revealed distinct associations between PTB and maternal factors for Black/White women. This study highlights the need for research assessing the relationships between social risk factors such as colorism and racism and the outcome of PTB, and it provides evidence that may inform more targeted PTB prevention among Black/White and Black women.

SARS-CoV-2 vaccine testing and trials in the pediatric population: biologic, ethical, research, and implementation challenges

As the nation implements SARS-CoV-2 vaccination in adults at an unprecedented scale, it is now essential to focus on the prospect of SARS-CoV-2 vaccinations in pediatric populations. To date, no children younger than 12 years have been enrolled in clinical trials. Key challenges and knowledge gaps that must be addressed include (1) rationale for vaccines in children, (2) possible effects of immune maturation during childhood, (3) ethical concerns, (4) unique needs of children with developmental disorders and chronic conditions, (5) health inequities, and (6) vaccine hesitancy. Because COVID-19 is minimally symptomatic in the vast majority of children, a higher acceptable risk threshold is required when evaluating pediatric clinical trials. Profound differences in innate and adaptive immunity during childhood and adolescence are known to affect vaccine responsiveness for a variety of childhood diseases. COVID-19 and the accompanying social disruption, such as the school shutdowns, has been disproportionately damaging to minority and low-income children. In this commentary, we briefly address each of these key issues, specify research gaps, and suggest a broader learning health system approach to accelerate testing and clinical trial development for an ethical and effective strategy to implement a pediatric SARS-CoV-2 vaccine as rapidly and safely as possible. IMPACT: As the US begins an unprecedented implementation of SARS-CoV-2 vaccination, substantial knowledge gaps have yet to be addressed regarding vaccinations in the pediatric population. Maturational changes in the immune system during childhood have influenced the effectiveness of pediatric vaccines for other diseases and conditions, and could affect SARS-CoV-2 vaccine responsiveness in children. Given that COVID-19 disease is far milder in the majority of children than in adults, the risk-benefit of a pediatric SARS-CoV-2 vaccine must be carefully weighed. The needs of children with developmental disabilities and with chronic disease must be addressed. Minority and low-income children have been disproportionately adversely affected by the COVID-19 pandemic; care must be taken to address issues of health equity regarding pediatric SARS-CoV-2 vaccine trials and allocation. Research and strategies to address general vaccine hesitancy in communities must be addressed in the context of pediatric SARS-CoV-2 vaccines.

Body composition and neuromotor development in the year after NICU discharge in premature infants

BACKGROUND

Hypothesis: neuromotor development correlates to body composition over the first year of life in prematurely born infants and can be influenced by enhancing motor activity.

METHODS

Forty-six female and 53 male infants [27 ± 1.8 (sd) weeks] randomized to comparison or exercise group (caregiver provided 15-20 min daily of developmentally appropriate motor activities) completed the year-long study. Body composition [lean body and fat mass (LBM, FM)], growth/inflammation predictive biomarkers, and Alberta Infant Motor Scale (AIMS) were assessed.

RESULTS

AIMS at 1 year correlated with LBM (r = 0.32, p < 0.001) in the whole cohort. However, there was no effect of the intervention. LBM increased by ~3685 g (p < 0.001)); insulin-like growth factor-1 (IGF-1) was correlated with LBM (r = 0.36, p = 0.002). IL-1RA (an inflammatory biomarker) decreased (-75%, p < 0.0125). LBM and bone mineral density were significantly lower and IGF-1 higher in the females at 1 year.

CONCLUSIONS

We found an association between neuromotor development and LBM suggesting that motor activity may influence LBM. Our particular intervention was ineffective. Whether activities provided largely by caregivers to enhance motor activity in prematurely born infants can affect the interrelated (1) balance of growth and inflammation mediators, (2) neuromotor development, (3) sexual dimorphism, and/or (4) body composition early in life remains unknown.

A School-Based Intervention Using Health Mentors to Address Childhood Obesity by Strengthening School Wellness Policy

Purpose and Objectives

The objective of our study was to strengthen wellness policy in Title 1 schools by implementing a mentored behavior-change model that extends the continuum of care from academic to community settings and mobilizes existing public resources in accordance with US Preventive Services Task Force screening guidelines for childhood obesity management.

Intervention Approach

Team Kid POWER! (KiPOW!) health mentors (students and trainees in medical and health-related fields) in 2 geographically and demographically distinct school districts, the District of Columbia and Orange County, California, delivered standardized health curricular modules to fifth grade classrooms, modeled healthy eating behaviors during school lunchtime, and engaged in active play at recess.

Evaluation Methods

Initial interventions in the the District of Columbia and Orange County delivered 10 sessions in which all participants received the intervention. Two subsequent interventions in Orange County, for 5 weeks (Lite) and 10 weeks (Full), included controls. Pre–post measurements of body mass index (BMI) and blood pressure were documented in all participants. A mixed linear regression model, which included a random effect for each school, estimated differences between Full and Lite interventions compared with controls, adjusting for site, sex, and baseline status of the dependent variable.

Results

KiPOW! Full, but not KiPOW! Lite, was associated with a modest reduction in BMI percentile compared with control (KiPOW! Full, P = .04; KiPOW! Lite, P = .41), especially in Orange County (P < .001). Systolic blood pressure improved in Full (P < .046) more than in Lite interventions (P = .11), and diastolic blood pressure improved in both Full (P = .02) and Lite (P = .03) interventions. Annual renewal of the school and volunteer commitment needed to maintain KiPOW! was found to be sustainable.

Implications for Public Health

KiPOW! is a generalizable academic–community partnership promoting face-to-face contact between students and trusted health mentors to reinforce school wellness policies and foster youth confidence in decision-making about nutrition- and activity-related behaviors to achieve reduced BMI percentile and lowered blood pressure.

Development of the Parent Perceptions of Physical Activity Scale (PPPAS): Results from two studies with parents of infants and toddlers

Physical activity (PA) is important from birth to promote health and motor development. Parents of young children are gatekeepers of opportunities for PA, yet little is known about their perceptions of PA. We describe the development of the Parent Perceptions of Physical Activity Scale (PPPAS) across two studies (N = 241 parents). In Study 1, 143 parents of infants and toddlers recruited from neonatal intensive care units (NICUs) and childcare centers completed a 48-item PPPAS. In Study 2, 98 parents of premature infants completed the revised 34-item PPPAS. Study 1 principal components analysis (PCA) identified three components (benefits of, barriers to, and perceived influence on PA), and the scale was reduced. Scores for Perceived Barriers to PA were significantly different between groups, U = 1,108, z = -4.777, p < .0001, with NICU parents reporting more barriers to PA than childcare parents. In Study 2, PCA revealed the same components, and the scale was further reduced to 25 items. Three subscales measuring perceived benefits of, barriers to, and influence over an infant's PA produced Cronbach's alphas of .93, .85, .81, respectively. Results demonstrated sufficient construct validity and internal consistency of PPPAS scores, supporting its use in future PA research.

Cultural understanding, experiences, barriers, and facilitators of healthcare providers when providing preconception counseling to adolescent Latinas with diabetes

Background

Latinas are at a higher risk than Caucasians for both type 1 and type 2 diabetes (DM), as well as DM-associated reproductive health (RH) complications. Healthcare providers (HCPs) should deliver culturally-sensitive care to enhance the care relationship between Latinos and HCPs and to improve patient outcomes. This study explored an expert panel's cultural understanding, experiences, barriers, and facilitators regarding RH and preconception counseling (PC) for adolescent Latinas with DM and their families.

Methods

This study used open-ended questions with a focus group of 8 HCPs from the mid-Atlantic, Southwest, and Northwest regions of the United States in a teleconference format. Two researchers transcribed and reviewed the transcript for accuracy. Using content analysis, four members of the team identified themes. All researchers discussed themes and a 100% consensus was reached. For confirmation, a coding protocol was created based on the emerging themes.

Results

Five themes related to cultural understanding and experiences were identified: 1) issues of identity; 2) acculturation; 3) stigma; 4) ambivalence toward birth control, RH education, and PC; and 5) cultural sensitivity vs. best practice. Four barriers were identified: 1) language; 2) religion; 3) access to healthcare, and 4) discomfort with discussion. Ten facilitators were identified: 1) the importance of support and support networks; 2) promoting trust among HCPs, daughters, and families; 3) assessing emotional development; 4) empowerment; 5) emphasizing safety; 6) communicating in patients' preferred language; 7) discussing RH-related topics and PC using cultural sensitivity; 8) importance of being ready/temporality/planning for the future; 9) the importance of family-centered care; and 10) variation in educational tailoring and dissemination/ care delivery.

Conclusions

Findings support the need for culturally sensitive and developmentally appropriate PC programs to empower adolescent Latinas with DM.

Measuring Maternal Behaviors in the Neonatal Intensive Care Unit

One of the most important considerations in designing clinical infant research studies is the selection of reliable and valid measurement procedures. Few measures of caregiver-child interactions have been studied with newborns, particularly premature infants. The main objective of this study was to examine psychometric properties of the NICHD Mother-Child Interaction Qualitative Ratings in a sample of premature infants and their mothers to evaluate its use in the Neonatal Intensive Care Unit (NICU). Mother-baby dyads (N=24) were videotaped in a 10-minute interaction in the NICU. Nine raters independently assessed dyadic interactions using the NICHD Mother-Child Interaction Qualitative Ratings in a fully-crossed research design. Rater reliability was strong for mother and infant ratings, (.76 to .94). Scores yielded normal distributions for maternal sensitivity, positive regard, and flatness of affect and skewed distributions for maternal intrusiveness, detachment, negative regard, and all child ratings. Positive maternal behaviors correlated positively with one another and negatively with negative maternal behaviors. Thus, preliminary analyses suggest that scores obtained using the NICHD Mother-Child Interaction Qualitative Ratings with premature babies and their mothers in the NICU demonstrate adequate inter-rater reliability, and distributional properties provide preliminary evidence of face validity.

Characteristics Associated With Adding Cereal Into the Bottle Among Immigrant Mother-Infant Dyads of Low Socioeconomic Status and Hispanic Ethnicity

OBJECTIVE

Determine maternal and infant characteristics associated with adding cereal into the bottle.

DESIGN

Secondary data analysis.

PARTICIPANTS

Study participants were immigrant, low-income, urban mother-infant dyads (n = 216; 91% Hispanic, 19% US-born) enrolled in a randomized controlled trial entitled the Bellevue Project for Early Language, Literacy and Education Success.

MAIN OUTCOME MEASURES

Maternal characteristics (age, marital status, ethnicity, primary language, country of origin, education, work status, income, depressive symptoms, and concern about infant's future weight) and infant characteristics (gender, first born, and difficult temperament).

ANALYSIS

Fisher exact test, chi-square test, and simultaneous multiple logistic regression of significant (P < .05) variables identified in unadjusted analyses.

RESULTS

Twenty-seven percent of mothers added cereal into the bottle. After adjusting for confounding variables identified in bivariate analyses, mothers who were single (P = .02), had moderate to severe depressive symptoms (P = .01) and perceived their infant had a difficult temperament (P = .03) were more likely to add cereal into the bottle. Conversely, mothers who expressed concern about their infants becoming overweight were less likely to add cereal (P = .02).

CONCLUSIONS AND IMPLICATIONS

Health care providers should screen for adding cereal in infant bottles. Further research is needed to investigate the impact of adding cereal into the bottle on weight trajectories over time. Causal associations also need to be identified to effectively prevent this practice.

The biosynthesis of phosphatidylinositol in human platelets

Homogenates of human platelets can mediate the synthesis of phosphatidylinositol from myoinositol and cytidine diphosphate diglyceride. The cytidine diphosphate diglyceride: myoinositol, phosphatidyl transferase activity is particulate-bound, and the highest specific activity is found in the membrane fraction. The production of phosphatidylinositol is decreased by sulfhydryl-binding agents, and the addition of thiols to the platelet homogenates increases the enzymatic activity. The reaction exhibits a pH optimum of 8.5-9.0. Divalent cations stimulate the reaction, and manganous chloride was the most effective of those investigated. The K(m) of the enzyme for myoinositol is 0.27 mM, and the K(m) for cytidine diphosphate diglyceride is 0.53 mM. The enzymatic activity of platelets isolated from patients with several diseases known to interfere with platelet clotpromoting function is similar to the enzymatic activity of platelets from normal donors.