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Objective: To examine the association between adverse social determinants of health (SDH) and missed well-child visits and the interaction with the level of caregiver social support. Methods: This is a secondary data analysis of data collected from a SDH screening program conducted during well-child visits with referral, navigation and follow-up services for patients. We included 573 adult caregivers who accompanied patients aged 0-5 years to well-child visits and completed the screening from August 2017 to May 2018. The caregivers reported financial hardship, food insecurity, housing challenges, childcare difficulty, transportation issues, insurance difficulty, job difficulty, and education needs. Our primary outcome was a no-show (i.e., missed) to a well-child visit. Social support was dichotomized as low or high. Results: Among 573 patients who completed the screening, 335 patients (76.4%) had at least one social need. Financial hardship (p = 0.006), housing instability (p = 0.002), and no/poor childcare (p = 0.03) were associated with missed well-child visits. In multivariable regression analysis, having Medicaid (aOR = 1.91 [1.17-3.10]) and unstable housing (aOR = 6.79 [1.35-34.70]) were both associated with missed well-child visits. However, when social support was added to the multivariable logistic model, both Medicaid and unstable housing were no longer associated with missed well-child visits. Conclusion: Adverse SDH such as financial hardship, housing instability, and childcare difficulty were associated with missed well-child visits. However, with the addition of social support, this association was no longer significant. This study supports the hypothesis that high social support may mitigate the association between well-child visits among families experiencing adverse SDH.

Additional file 1. SURVEY: Cross-Cultural Aspects of Care.

Background There is an increasing shortage of primary care physicians in the U.S. The difficult task of addressing patients’ sociocultural needs is one reason residents do not pursue primary care. However, associations between residents’ perceived barriers to cross-cultural care provision and career interest in primary care have not been investigated. Objective We examined residents’ career interest in primary care and associations with resident characteristics and their perceived barriers in providing cross-cultural care. Methods We conducted a cross-sectional analysis of a resident survey from the 2018–2019 academic year. We first described residents’ sociodemographic characteristics based on their career interest in primary care (Chi-square test). Our primary outcome was high career interest in primary care. We further examined associations between residents’ characteristics and perceived barriers to cross-cultural care. Results The study included 155 family medicine, pediatrics, and internal medicine residents (response rate 68.2%), with 17 expressing high career interest in primary care. There were significant differences in high career interest by race/ethnicity, as Non-White race was associated with high career interest in primary care (p p-values Conclusion Residents from diverse racial/ethnic and socioeconomic backgrounds demonstrated higher career interest in primary care and perceived more barriers to cross-cultural care, underscoring the importance of increasing physician workforce diversity to address the primary care shortage and to improve cross-cultural care.

Background and Aims United States Medical Licensing Exam (USMLE) scores are the single, most objective criteria for admission into residency programs in the country. Underrepresented minorities in medicine (URiM) are found to have lower USMLE scores compared to their White counterparts. The objective of this study is to examine how USMLE step 1 cutoff scores may exclude self‐reported URiM from the residency interview process across various specialties. Methods This was a retrospective cross‐sectional study of 10 541 applicants to different residency programs at Zucker School of Medicine at Hofstra/Northwell Health between May 2014 and May 2015. We identified Blacks and Hispanics as URiM. The primary outcome is the percentage of applicants with USMLE step 1 score above different ranges of cutoff score, from 205 to 235 in five‐point increments, by race/ethnicity and by URiM status. Secondary outcome is percentages of URiM vs non‐URiM above and below mean USMLE step 1 scores by different specialties (internal medicine, obstetrics/gynecology, pediatrics, and psychiatry). Results The study sample included 2707 White, 722 Black, 805 Hispanic, 5006 Asian, and 562 Other Race/Ethnicity applicants. Overall, 50.2% were male, 21.3% URiM, 7.4% had limited English proficiency, 67.6% attended international medical schools, and 2.4% are Alpha Omega Alpha Honor Medical Society (AOA) members. The mean (±SD) USMLE step 1 score was significantly greater among non‐URiM applicants as compared to URiM applicants (223.7 ± 19.4 vs 216.1 ± 18.4, P

Background: Social determinants of health (SDH) account for a large percentage of health outcomes. Therefore, ensuring providers can address SDH is paramount yet curricula in this area is limited. Aim: The authors aimed to raise awareness, identify learning opportunities, foster positive attitudes, and equip educators to implement SDH curriculum. Setting and participants: This retreat occurred at a large academic institution and had over 130 participants who represented 56 distinct training programs and over 20 disciplines. Program description: The retreat was titled “Social Determinants of Health: Walking in Your Patients’ Shoes.” The retreat was holistic and used a multidimensional approach that included traditional learning, team-based learning, reflective practice, and prompted action. Program evaluation: The evaluation of this retreat included electronic surveys and both qualitative and quantitative data. The retreat’s quality and effectiveness at improving participants’ knowledge and skill in addressing SDH was highly rated and resulted in numerous programs, including surgical and subspecialty programs reporting adopting SDH curricular and clinical workflow changes. Discussion: The retreat was successful and reached a wide and diverse set of faculty educators and can serve as an education model to the graduate medical education community on how to start to develop “physician-citizens.”

Although the integration of social determinants of health (SDH) screening and referral programs in clinical settings has rapidly grown, the voice and experience of participants within SDH programs has not been well understood in program evaluations. To qualitatively evaluate a comprehensive SDH screening and referral program based in an academic primary care setting, we conducted a qualitative analysis of a semi-structured, focus group interview of 7 caregivers. We performed inductive coding representing emerging ideas from each transcript using focus group transcripts from families who participated in the SDH screening and referral program. A thematic model was created describing caregivers’ experiences with respect to screening, intake, and referral phases of the program. Caregivers reported satisfaction with structural and process-related components of screening, intake, and referral. They expressed a preference for trained patient navigators over physicians for screening and intake for they were perceived to have time to prioritize caregivers’ social needs. Caregivers reported disappointment with legal services screening, intake, and referral, citing lack of timely contact from the legal resource team and prematurity of provided legal resources. Overall, caregivers recommend the program, citing that the program provided social support, an environment where expression is encouraged, motivation to address their own health needs, and a convenient location. Overall, caregivers would recommend the program because they feel socially supported. The use of trained patient navigators appears to be instrumental to the successful implementation of the program in clinics, for navigators can provide caregivers with the appropriate time and personal attention they need to complete the survey and discuss their needs. Streamlining the referral process for evaluation of health-harming needs by the medical legal partnership was highlighted as an area for improvement.

* Abbreviations: AAP — : American Academy of Pediatrics ABP — : American Board of Pediatrics APPD — : Association of Pediatric Program Directors ETC — : Education and Training Committee GH — : global health GHLC — : Global Health Learning Community GHTF — : Global Health Task Force LMIC — : low- and middle-income country SOICH — : Section on International Child Health Pediatric trainees are increasingly seeking global health (GH) educational opportunities, with ∼1 in 4 participating in a GH elective during residency.1,2 Training programs have responded to this demand: surveys suggest that ∼58% of residency and 47% of fellowship training programs offer GH electives.3,4 In accordance with best practices pertaining to short-term GH electives, many programs are attempting to build GH training opportunities beyond electives, including longitudinal GH curricula at their respective institutions, predeparture preparation training, postreturn debriefing, and global training partnerships.1,2,4–11 Concomitantly, educators are recognizing that all trainees, not just those planning to work abroad, need to learn about GH-related topics. The “local global health” framework12 highlights that diseases do not respect borders, resource limitation is not unique to low- and middle-income countries (LMICs), and core skills are necessary for all trainees caring for patients and families from (and going to) diverse settings. These skills include using interpreters effectively, caring for immigrants and travelers, employing … Address correspondence to Nicole E. St Clair, MD, Department of Pediatrics, University of Wisconsin–Madison School of Medicine and Public Health, H4/477 Mailcode 4108, 600 Highland Ave, Madison, WI 53792-4108. E-mail: nstclair{at}wisc.edu

BACKGROUND: Global health (GH) offerings by pediatric residency programs have increased significantly, with 1 in 4 programs indicating they offer a GH track. Despite growth of these programs, there is currently no widely accepted definition for what comprises a GH track in residency. METHODS: A panel of 12 pediatric GH education experts was assembled to use the Delphi method to work toward a consensus definition of a GH track and determine essential educational offerings, institutional supports, and outcomes to evaluate. The panelists completed 3 rounds of iterative surveys that were amended after each round on the basis of qualitative results. RESULTS: Each survey round had 100% panelist response. An accepted definition of a GH track was achieved during the second round of surveys. Consensus was achieved that at minimum, GH track educational offerings should include a longitudinal global child health curriculum, a GH rotation with international or domestic underserved experiences, predeparture preparation, preceptorship during GH electives, postreturn debrief, and scholarly output. Institutional supports should include resident salary support; malpractice, evacuation, and health insurance during GH electives; and a dedicated GH track director with protected time and financial and administrative support for program development and establishing partnerships. Key outcomes for evaluation of a GH track were agreed on. CONCLUSIONS: Consensus on the definition of a GH track, along with institutional supports and educational offerings, is instrumental in ensuring consistency in quality GH education among pediatric trainees. Consensus on outcomes for evaluation will help to create quality resident and program assessment tools.

Purpose of review This paper provides a brief overview of the current landscape of global child health and the impact of social determinants on the world's children. In the United States (US), global child health (GCH) has increasingly been highlighted as a priority area by national organizations, such as the National Academy of Medicine and American Academy of Pediatrics, as well as individual pediatricians committed to ensuring the health of all children regardless of geographic location. Although GCH is commonly used to refer to the health of children outside of the US, here, we highlight the recent call for GCH to also include care of US vulnerable children. Many of the lessons learned from abroad can be applied to pediatrics domestically by addressing social determinants that contribute to health disparities. Recent findings Using the 'three-delay' framework, effective global health interventions target delays in seeking, accessing, and/or receiving adequate care. In resource-limited, international settings, novel health system strengthening approaches, such as peer groups, community health workers, health vouchers, cultural humility training, and provision of family-centered care, can mitigate barriers to healthcare and improve access to medical services. Summary The creative use of limited resources for pediatric care internationally may offer insight into effective strategies to address health challenges that children face here in the US. The growing number of child health providers with clinical experience in resource-limited, low-income countries can serve as an unforeseen yet formidable resource for improving pediatric care in underserved US communities.

Appeals for health equity call for departments of pediatrics to improve the health of all children including those from underserved communities in North America and around the world. Consequently, North American (NA) departments of pediatrics have a role in global child health (GCH) which focuses on providing health care to underserved children worldwide. In this review, we describe how NA departments of pediatrics can collaboratively engage in GCH education, clinical practice, research, and advocacy and summarize best practices, challenges, and next steps for engaging in GCH in each of these areas. For GCH in low- and middle-income countries (LMICs), best practices start with the establishment of ethical, equitable, and collaborative partnerships with LMIC communities, organizations, and institutions engaged in GCH who are responsible for the vast majority of work done in GCH. Other best practices include adequate preparation of trainees and clinicians for GCH experiences; alignment with local clinical and research priorities; contributions to local professional development and ongoing monitoring and evaluation. Challenges for departments include generating funding for GCH activities; recruitment and retention of GCH-focused faculty members; and challenges meeting best practices, particularly adequate preparation of trainees and clinicians and ensuring mutual benefit and reciprocity in NA–LMIC collaborations. We provide examples of how departments have overcome these challenges and suggest next steps for development of the role of NA departments of pediatrics in GCH. Collaborative implementation of best practices in GCH by LMIC–NA partnerships can contribute to reductions of child mortality and morbidity globally.

BackgroundPneumonia remains the leading cause of child mortality in sub-Saharan Africa. The Integrated Management of Childhood Illness (IMCI) strategy was developed to standardise care in low-income and middle-income countries for major childhood illnesses and can effectively improve healthcare worker performance. Suboptimal clinical evaluation can result in missed diagnoses and excess morbidity and mortality. We estimate the sensitivity of pneumonia diagnosis and investigate its determinants among children in Malawi.MethodsData were obtained from the 2013–2014 Service Provision Assessment survey, a census of health facilities in Malawi that included direct observation of care and re-examination of children by trained observers. We calculated sensitivity of pneumonia diagnosis and used multilevel log-binomial regression to assess factors associated with diagnostic sensitivity.Results3136 clinical visits for children 2–59 months old were observed at 742 health facilities. Healthcare workers completed an average of 30% (SD 13%) of IMCI guidelines in each encounter. 573 children met the IMCI criteria for pneumonia; 118 (21%) were correctly diagnosed. Advanced practice clinicians were more likely than other providers to diagnose pneumonia correctly (adjusted relative risk 2.00, 95% CI 1.21 to 3.29). Clinical quality was strongly associated with correct diagnosis: sensitivity was 23% in providers at the 75th percentile for guideline adherence compared with 14% for those at the 25th percentile. Contextual factors, facility structural readiness, and training or supervision were not associated with sensitivity.ConclusionsCare quality for Malawian children is poor, with low guideline adherence and missed diagnosis for four of five children with pneumonia. Better sensitivity is associated with provider type and higher adherence to IMCI. Existing interventions such as training and supportive supervision are associated with higher guideline adherence, but are insufficient to meaningfully improve sensitivity. Innovative and scalable quality improvement interventions are needed to strengthen health systems and reduce avoidable child mortality.

* Abbreviation: DACA — : Deferred Action for Childhood Arrivals > What happens to a dream deferred? Does it dry up like a raisin in the sun?. . . Or does it explode? > > Langston Hughes On June 15, 2012, the Obama administration issued a memorandum providing protection from deportation for a group of immigrant adolescents and young adults who were brought as children to the United States without authorization. This memorandum, Deferred Action for Childhood Arrivals (DACA), has to date protected nearly 800 000 of the 1.9 million potentially eligible individuals (Table 1), including 228 000 children

Objective The number of pediatric Global Health (GH) tracks has more than doubled in less than 10 years. The goal of this study was to describe the characteristics of the pediatric GH tracks to identify commonalities and differences in track structure, funding, and education. In addition, we also identified demographic, institutional, and residency-related factors that were significantly associated with educational offerings and logistical challenges. Methods A cross-sectional survey was electronically administered to pediatric residency programs with GH tracks. Statistical analyses included frequencies to describe GH track characteristics. Fisher's exact tests were used to identify bivariate associations between track structure and funding with educational offerings and logistical challenges. Results Leaders of 32 pediatric GH tracks (67%) completed the survey. The majority of GH tracks were completed within the 3 years of residency (94%) and identified a GH track director (100%); however, tracks varied in size, enrollment methods, domestic and international partnerships, funding, and evaluations. Dedicated faculty time and GH track budget amounts were associated with more robust infrastructure pertaining to resident international electives, including funding and mentorship. Many tracks did not meet American Academy of Pediatrics recommended standards for clinical international rotations. Conclusions Despite the presence of multiple similarities among pediatric GH tracks, there are large variations in track structure, education, and funding. The results from this study support the proposal of a formal definition and minimum standards for a GH track, which may provide a framework for quality, consistency, and comparison of GH tracks.

Background Resident scholarly activity is desirable component of a pediatric training program. Frequently cited challenges include mentorship and time. To address these issues the training program at Cohen Children's Medical Center designed a three year process to promote resident scholarly activity through enhanced mentorship and protected time. Objective The objective of this longitudinal curriculum was to increase resident involvement in scholarly activity. Methods In 2013 the pediatric program launched a longitudinal curriculum to promote resident scholarly productivity. The program included the following major curricular elements: (1) A two week research/quality improvement rotation in the PGY1 year. This rotation included individual meetings with senior faculty, completion of 6 on-line research modules, SPSS statistical training, completion of the CITI Course, instruction on the formulation of a research question and the creation of an individual scholarly activity timeline. This was followed by (2) Semiannual Scholarly Oversight Committee Meetings, (3) 1-2 dedicated research blocks for individual residents and an opportunity to present at an Annual Pediatric Resident Research Day. Funding for residents to present at national meetings was made available. Results Scholarly activity, as defined by the number of resident presentations at a national meetings, has increased substantially from 2013-2017. When the curriculum was introduced 7 out of 100 residents had either a poster or platform presentation accepted to a national meeting. This number increased steadily year over year and has reached 40 presentations in 2017. Conclusion A longitudinal curriculum focused on scholarly achievement was successful in increasing resident scholarly output. This curriculum can be easily emulated at other programs to increase resident scholarly productivity.

Background GME programs that provide targeted training on the care of disadvantaged populations may result in improved cross-cultural care and decreased health disparities and patient discrimination. In 2018, the ACGME highlighted lack of formal education on knowledge and strategies to address health disparities as a national priority need. Currently, many residents do not receive training on structural competencies and biases that contribute to poor health, nor are they equipped with skills to advocate for patients who disproportionately experience inequity from structural and social determinants of health (SDOH). Design The HEDI curriculum at Cohen Children's Medical Center expands resident training to include sessions on: implicit bias, use of interpreters, health literacy, health disparities, community engagement, LGBTQ health, mistrust, racism, SDOH, cultural and structural competency. Prior to curriculum initiation, residents completed the validated Cross-Cultural Care Survey (CCCS). Trainees engage in monthly, interactive workshops and case-based simulations. Pre and post surveys assess resident knowledge, skill, and attitudes related to each session. Descriptive analyses and Fisher's Exact Test assess bivariate associations. Results Of the 49 residents who completed the CCCS, 67% felt unprepared to deliver cross-cultural care. 18% identified lack of experience and 30% reported inadequate training as barriers to delivering cross-cultural care. Attendance of at least 1 HEDI session was associated with a decrease in residents personal feeling of helplessness when caring for patients of different cultures (p Conclusion Early results from the HEDI curriculum show residents' improvement in preparedness and attitudes in providing cross-cultural care. Further research is warranted to examine whether curricular elements provide a long-term, sustained impact on resident knowledge, skills, and attitudes, which are necessary to combat and eliminate health disparities.

BackgroundAccording to the World Health Organization, >200 million children in low- and middle-income countries experience developmental delays. However, household structure and parenting practices have been minimally explored as potential correlates of developmental delay in low- and middle-income countries, despite potential as areas for intervention.ObjectiveThe objective of the study was to examine associations of developmental delays with use of World Health Organization–recommended parenting practices among a clinic-based cohort of children aged 6-60 months attending in La Romana, Dominican Republic.MethodsThis study was conducted among 74 caregiver-child pairs attending the growth-monitoring clinic at Hospital Francisco Gonzalvo in June 2015. The Malawi Developmental Assessment Tool was adapted and performed on each child to assess socioadaptive, fine motor, gross motor, and language development. The IMCI Household Level Survey Questionnaire was used to assess parenting practices. Fisher's exact test was used to determine associations significant at 'P' FindingsAlmost two-thirds of children had a delay in at least 1 developmental domain. Most caregivers used scolding (43.2%) or spanking (44%) for child discipline. Children who were disciplined by spanking and scolding were more likely to have language delay ('P' = .007) and socioadaptive delay ('P' = .077), respectively. On regression analysis, children with younger primary caregivers had 7 times higher odds of language delay (adjusted odds ratio [AOR]: 7.35, 95% confidence interval [CI]: 1.52-35.61) and 4 times greater odds of any delay (AOR: 4.72, 95% CI: 1.01-22.22). In addition, children punished by spanking had 5 times higher odds of having language delay (AOR: 5.04, 95% CI: 1.13-22.39).ConclusionsParenting practices such as harsh punishment and lack of positive parental reinforcement were found to have strong associations with language and socioadaptive delays. Likewise, delays were also more common among children with younger caregivers.