Janine Bruce

All Publications

• Training for transformation: examining food systems courses at US land-grant universities FRONTIERS IN SUSTAINABLE FOOD SYSTEMS Hoffs, C. T., Chharan, N., Landry, M. J., Ward, C. P., Oyewole, K. A., Wang, M. C., Egan, S., Bruce, J., Gardner, C. 2024; 8

  View details for DOI 10.3389/fsufs.2024.1472789

  View details for Web of Science ID 001345231200001

• Addressing the Childcare Gap of Siblings of Hospitalized Children. Hospital pediatrics Rose, L., Williams, N., Lee, H. C., Bruce, J. 2024

  View details for DOI 10.1542/hpeds.2024-007760

  View details for PubMedID 39359197

• Educational Values of Latino Families Participating in a School Readiness Intervention: Hopes and Implications for Pediatrics. Journal of developmental and behavioral pediatrics : JDBP Peterson, J. W., Robles, A., Underwood Carrasco, V. I., Zavala, J., Almanzar, N., Zuckerman, K. E., Bruce, J. 2024

  Abstract

  OBJECTIVE: To explore Latino parents' educational values and hopes for their preschool-aged children after a clinic school readiness (SR) intervention.METHODS: Qualitative analysis of semi-structured interviews of Latino parents regarding their perceptions of a novel SR coaching intervention (2016-2017). Parents who received the intervention were approached for interview (n = 74); 59 postintervention interviews were completed in English or Spanish, audio recorded, transcribed, and translated into English. Iterative team-based coding and inductive thematic analysis of 47 interviews were conducted by 3 team members using Dedoose.RESULTS: Children were on average 4.5 years old, with the majority speaking Spanish at home (57%), and having preschool experience (81%). Mothers mostly had no paid employment (53%) and limited formal education. Four domains emerged: 1) education is valued and seen as a pathway to a successful life for children, and 2) while structural and cultural barriers exist, 3) Latino families are motivated and 4) trust providers to offer SR support. Parents suggested pediatricians could provide more SR knowledge to families and offer programs within primary care. Integration of findings are summarized in a framework for clinical practice.CONCLUSION: Latino parents' trust in their pediatric providers, combined with their strong educational aspirations for their children, offers the pediatric clinic an opportunity to partner with families to reduce systemic SR barriers. Pediatric providers can support Latino parents in preparing their children for school through culturally responsive, strengths-based approaches that build on their educational aspirations, value existing SR efforts, offer SR knowledge around early literacy and math, and build connections to early childhood programs.

  View details for DOI 10.1097/DBP.0000000000001295

  View details for PubMedID 38904654

• Meeting the Needs of Postpartum Women: Provider Perspectives on Maternal Contraceptive Care in Pediatric Settings ACADEMIC PEDIATRICS Trope, L. A., Congdon, J. L., Bruce, J. S., Chung, P. J., Dehlendorf, C., Chamberlain, L. J. 2023; 23 (4): 821-828

  View details for Web of Science ID 001009428200001

• Parent Perception of School Meals in the San Joaquin Valley during COVID-19: A Photovoice Project. Nutrients Sohlberg, T. M., Higuchi, E. C., Ordonez, V. M., Escobar, G. V., De La Rosa, A., Islas, G., Castro, C., Hecht, K., Hecht, C. E., Bruce, J. S., Patel, A. I. 2023; 15 (5)

  Abstract

  School-based nutrition programs are crucial to reducing food insecurity. The COVID-19 pandemic adversely impacted students' school meal participation. This study seeks to understand parent views of school meals during COVID-19 to inform efforts to improve participation in school meal programs. Photovoice methodology was used to explore parental perception of school meals in San Joaquin Valley, California, a region of predominately Latino farmworker communities. Parents in seven school districts photographed school meals for a one-week period during the pandemic and then participated in focus group discussions and small group interviews. Focus group discussions and small group interviews were transcribed, and data were analyzed using a team-based, theme-analysis approach. Three primary domains emerged: benefits of school meal distribution, meal quality and appeal, and perceived healthfulness. Parents perceived school meals as beneficial to addressing food insecurity. However, they noted that meals were unappealing, high in added sugar, and unhealthy, which led to discarded meals and decreased participation in the school meal program. The transition to grab-and-go style meals was an effective strategy for providing food to families during pandemic school closures, and school meals remain an important resource for families experiencing food insecurity. However, negative parental perceptions of the appeal and nutritional content of school meals may have decreased school meal participation and increased food waste that could persist beyond the pandemic.

  View details for DOI 10.3390/nu15051087

  View details for PubMedID 36904087

• PROTECTION, PAIN, AND PRIDE: PARENTING AND BUILDING MOTHER-CHILD RELATIONSHIPS AMID DOMESTIC VIOLENCE IN A PRIMARILY LATINO COMMUNITY Reed, R. E., Bruce, J., Villa, E., Peralez-Dieckmann, E. ELSEVIER SCIENCE INC. 2022: S166

  View details for DOI 10.1016/j.jaac.2022.09.094

  View details for Web of Science ID 000873567900553

• Meeting the Needs of Postpartum Women: Provider Perspectives on Maternal Contraceptive Care in Pediatric Settings. Academic pediatrics Trope, L. A., Congdon, J. L., Bruce, J. S., Chung, P. J., Dehlendorf, C., Chamberlain, L. J. 2022

  Abstract

  OBJECTIVE: Closely spaced, mistimed, and unwanted pregnancies are common among postpartum women and can lead to adverse maternal and perinatal outcomes. Women inconsistently attend postpartum obstetric visits, though they reliably interface with pediatric providers during the postpartum months, presenting novel opportunities to identify and address unmet family planning needs.METHODS: We conducted a qualitative study to explore pediatric provider perspectives on addressing maternal family planning in three settings: a neonatal intensive care unit, a primary care clinic, and a high-risk infant follow-up clinic.RESULTS: Pediatric providers were generally open to incorporating postpartum family planning screening and counseling into a pediatric encounter, if given appropriate training and implementation support. Providers largely agreed that contraceptive provision to women was not feasible in their practices, and they shared ideas for utilizing the pediatric encounter to connect women with comprehensive contraceptive care.CONCLUSION: Pediatric providers perceived postpartum family planning screening and counseling, and not contraceptive provision, as potentially acceptable and feasible in their practice settings. These exploratory findings justify further investigation to assess their generalizability and to develop postpartum family planning interventions for pediatrics.

  View details for DOI 10.1016/j.acap.2022.08.013

  View details for PubMedID 36067921

• Communication Skills Training Using Remote Augmented Reality Medical Simulation: a Feasibility and Acceptability Qualitative Study. Medical science educator Hess, O., Qian, J., Bruce, J., Wang, E., Rodriguez, S., Haber, N., Caruso, T. J. 2022: 1-10

  Abstract

  Introduction: Augmented reality (AR) has promise as a clinical teaching tool, particularly for remote learning. The Chariot Augmented Reality Medical (CHARM) simulator integrates real-time communication into a portable medical simulator with a holographic patient and monitor. The primary aim was to analyze feedback from medical and physician assistant students regarding acceptability and feasibility of the simulator.Methods: Using the CHARM simulator, we created an advanced cardiovascular life support (ACLS) simulation scenario. After IRB approval, preclinical medical and physician assistant students volunteered to participate from August to September 2020. We delivered augmented reality headsets (Magic Leap One) to students before the study. Prior to the simulation, via video conference, we introduced students to effective communication skills during a cardiac arrest. Participants then, individually and remotely from their homes, synchronously completed an instructor-led ACLS AR simulation in groups of three. After the simulation, students participated in a structured focus group using a qualitative interview guide. Our study team coded their responses and interpreted them using team-based thematic analysis.Results: Eighteen medical and physician assistant students participated. We identified four domains that reflected trainee experiences: experiential satisfaction, learning engagement, technology learning curve, and opportunities for improvement. Students reported that the simulator was acceptable and enjoyable for teaching trainees communication skills; however, there were some technical difficulties associated with initial use.Conclusion: This study suggests that multiplayer AR is a promising and feasible approach for remote medical education of communication skills during medical crises.Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01598-7.

  View details for DOI 10.1007/s40670-022-01598-7

  View details for PubMedID 35966166

• Examination of an Intergenerational Summer Meal Program for Children and Older Adults. Journal of community health Bruce, J. S., Lien, T. N., George, E., Puri, V., Ramirez, M., Merrell, S. B. 2022

  Abstract

  Unreliable access to a sufficient quantity of affordable, nutritious food in the U.S. is a persistent public health threat significantly impacting households with children (15%) and older adults (20%). Well-established nutrition assistance programs serve children and seniors independently, yet few programs utilize an intergenerational meal program model. The aim of this mixed methods study is to examine the impact of an intergenerational meal program administered through a partnership between a local school district and a county Senior Nutrition Program. Participating older adults completed surveys to assess food security and program attendance, and examine their understanding and utilization of community-based food resources. Interviews with a subsample of participants explored perceptions of the intergenerational meal program and community-level food security. Older adults (n=83) completed surveys in English (59%), Spanish (25%), and Mandarin (16%). They identified primarily as Asian (44%), Latinx (30%), White (21%), and multi-racial (5%). Forty-eight percent of participants indicated low or very low food security at some time in the last 12months. The subsample of interviewparticipants (n=24; Spanish 46% and English 54%) revealed key insights: 1) perceived benefits of an intergenerational meal program; 2) community-level food insecurity and struggles of older adults to make ends meet; and 3) importance and challenge of obtaining nutritious foods for those with limited budgets and medical comorbidities. Implementation of this intergenerational meal program highlights the opportunity to support the nutritional needs of children and older adults while leveraging a new interdisciplinary partnership and existing organizational capacity.

  View details for DOI 10.1007/s10900-022-01125-0

  View details for PubMedID 35915322

• Anesthesiologists With Advanced Degrees in Education: Qualitative Study of a Changing Paradigm. JMIR medical education Aggarwal, A., Hess, O., Lockman, J. L., Smith, L., Stevens, M., Bruce, J., Caruso, T. 2022; 8 (2): e38050

  Abstract

  Anesthesiology education has undergone profound changes over the past century, from a pure clinical apprenticeship to novel comprehensive curricula based on andragogic learning theories. Combined with institutional and regulatory requirements, these new curricula have propagated professionalization of the clinician-educator role. A significant number of clinician-educator anesthesiologists, often with support from department chairs, pursue formal health professions education (HPE) training, yet there are no published data demonstrating the benefits or costs of these degrees to educational leaders.This study aims to collect the experiences of anesthesiologists who have pursued HPE degrees to understand the advantages and costs of HPE degrees to anesthesiologists.Investigators performed a qualitative study of anesthesiologists with HPE degrees working at academic medical centers. Interviews were thematically analyzed via an iterative process. They were coded using a team-based approach, and representative themes and exemplary quotations were identified.Seven anesthesiologists were interviewed, representing diverse geographic regions, subspecialties, and medical institutions. Analyses of interview transcripts resulted in the following 6 core themes: outcomes, extrinsic motivators, intrinsic motivators, investment, experience, and recommendations. The interviewees noted the advantages of HPE training for those wishing to pursue leadership or scholarship in medical education; however, they also noted the costs and investment of time in addition to preexisting commitments. The interviewees also highlighted the issues faculty and chairs might consider for the optimal timing of HPE training.There are numerous professional and personal benefits to pursuing HPE degrees for faculty interested in education leadership or scholarship. Making an informed decision to pursue HPE training can be challenging when considering the competing pressures of clinical work and personal obligations. The experiences of the interviewed anesthesiologists offer direction to future anesthesiologists and chairs in their decision-making process of whether and when to pursue HPE training.

  View details for DOI 10.2196/38050

  View details for PubMedID 35771619

• Anesthesiologists with Advanced Degrees in Education: A Qualitative Study of a Changing Paradigm Hess, O. M., Daniel, D., Aggarwal, A., Lockman, J., Smith, L. E., Stevens, M., Bruce, J., Caruso, T. LIPPINCOTT WILLIAMS & WILKINS. 2022: 388-389

  View details for Web of Science ID 000840283000149

• EXPANDING THE HEALTH PROFESSIONS PIPELINE: A QUALITATIVE ANALYSIS OF THE STANFORD MEDICAL YOUTH SCIENCE PROGRAM Pineda, N., Ramirez, M., Arreola, L., Shorter, A., Bruce, J., Winkleby, M. ELSEVIER SCIENCE INC. 2022: S65

  View details for Web of Science ID 000768696700121

• Kinder Ready Clinics: A Collaborative Model for Creating Equitable and Engaged Early Learning Environments for Low-income Families JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Bruce, J. S., De la Cruz, M. M., Thadani, R., Steinberg, J. R., Brewster, R., Chiu, S., Dunham, R., Ramphos, E., Ramirez, M., Chamberlain, L. J. 2022; 33 (1): 528-541

  Abstract

  Disparities in children's school readiness (SR) in the U.S. are well-documented and have detrimental long-term consequences. Clinic-based early education interventions are limited. This report summarizes collaborative efforts of pediatricians and community stakeholders to develop and implement clinic-based interventions to promote early learning and SR among low-income children.

  View details for Web of Science ID 000755078700011

  View details for PubMedID 35153240

• BEHAVIORAL RESPONSES TO A SEASONAL ENVIRONMENT REDUCE FREQUENCY BUT INCREASE EXTENT OF WATER CONTACT IN A SCHISTOSOMIASIS-ENDEMIC REGION OF WEST AFRICA Lund, A., Sam, M., Sy, A., Sow, O., Sokolow, S., Merrell, S., Bruce, J., Jouanard, N., Senghor, S., Riveau, G., De Leo, G., Lopez-Carr, D. AMER SOC TROP MED & HYGIENE. 2021: 405

  View details for Web of Science ID 000778105603359

• A Text-Based Intervention to Promote Literacy: An RCT. Pediatrics Chamberlain, L. J., Bruce, J., De La Cruz, M., Huffman, L., Steinberg, J. R., Bruguera, R., Peterson, J. W., Gardner, R. M., He, Z., Ordaz, Y., Connelly, E., Loeb, S. 2021

  Abstract

  BACKGROUND AND OBJECTIVES: Children entering kindergarten ready to learn are more likely to thrive. Inequitable access to high-quality, early educational settings creates early educational disparities. TipsByText, a text-message-based program for caregivers of young children, improves literacy of children in preschool, but efficacy for families without access to early childhood education was unknown.METHODS: We conducted a randomized controlled trial with caregivers of 3- and 4-year-olds in 2 public pediatric clinics. Intervention caregivers received TipsByText 3 times a week for 7 months. At pre- and postintervention, we measured child literacy using the Phonological Awareness Literacy Screening Tool (PALS-PreK) and caregiver involvement using the Parent Child Interactivity Scale (PCI). We estimated effects on PALS-PreK and PCI using multivariable linear regression.RESULTS: We enrolled 644 families, excluding 263 because of preschool participation. Compared with excluded children, those included in the study had parents with lower income and educational attainment and who were more likely to be Spanish speaking. Three-quarters of enrollees completed pre- and postintervention assessments. Postintervention PALS-PreK scores revealed an unadjusted treatment effect of 0.260 (P = .040); adjusting for preintervention score, child age, and caregiver language, treatment effect was 0.209 (P = .016), equating to 3 months of literacy gains. Effects were greater for firstborn children (0.282 vs 0.178), children in 2-parent families (0.262 vs 0.063), and 4-year-olds (0.436 vs 0.107). The overall effect on PCI was not significant (1.221, P = .124).CONCLUSIONS: The health sector has unique access to difficult-to-reach young children. With this clinic-based texting intervention, we reached underresourced families and increased child literacy levels.

  View details for DOI 10.1542/peds.2020-049648

  View details for PubMedID 34544847

• Mitigating Childhood Food Insecurity during COVID-19: A Qualitative Study of how School Districts in California's San Joaquin Valley Responded to Growing Needs. Public health nutrition Jowell, A. H., Bruce, J. S., Escobar, G. V., Ordonez, V. M., Hecht, C. A., Patel, A. I. 2021: 1-26

  Abstract

  OBJECTIVES: To explore best practices and challenges in providing school meals during COVID-19 in a low-income, predominantly Latino, urban-rural region.DESIGN: Semi structured interviews with school district stakeholders and focus groups with parents were conducted to explore school meal provision during COVID-19 from June to August 2020. Data was coded and themes were identified to guide analysis. Community organizations were involved in all aspects of study design, recruitment, data collection, and analysis.SETTING: Six school districts in California's San Joaquin Valley.PARTICIPANTS: School district stakeholders (n=11) included food service directors, school superintendents, and community partners (e.g., funders, food co-operative). Focus groups (n=6) were comprised of parents (n=29) of children participating in school meal programs.RESULTS: COVID-19-related challenges for districts included developing safe meal distribution systems, boosting low participation, covering COVID-19-related costs, and staying informed of policy changes. Barriers for families included transportation difficulties, safety concerns, and a lack of fresh foods. Innovative strategies to address obstacles included pandemic-EBT, bus-stop delivery, community pick-up locations, batched meals, and leveraging partner resources.CONCLUSIONS: A focus on fresher, more appealing meals and greater communication between school officials and parents could boost participation. Districts that leveraged external partnerships were better equipped to provide meals during pandemic conditions. In addition, policies increasing access to fresh foods and capitalizing on USDA waivers could boost school meal participation. Finally, partnering with community organizations and acting upon parent feedback could improve school meal systems, and in combination with pandemic-EBT, address childhood food insecurity.

  View details for DOI 10.1017/S1368980021003141

  View details for PubMedID 34325769

• Clinic-Based School Readiness: A Qualitative Examination of a Text Messaging Intervention JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Connelly, E., Ordaz, Y., Perez, J., De La Cruz, M. M., Chamberlain, L., Bruguera, R., Steinberg, J. R., Harris, S., Foreman, J., Bruce, J. 2021; 32 (2): 43-61

  View details for DOI 10.1353/hpu.2021.0050

  View details for Web of Science ID 000652618900007

• Puerto Rico Health System Resilience After Hurricane Maria: Implications for Disaster Preparedness in the COVID-19 Era FRONTIERS IN COMMUNICATION Rios, C. C., Ling, E. J., Rivera-Gutierrez, R., Sanchez, J., Merrell, S., Bruce, J., Barry, M., Perez, V. 2021; 5

  View details for DOI 10.3389/fcomm.2020.593939

  View details for Web of Science ID 000677962900001

• Pediatric Departmental Advocacy: Our Experience Addressing the Social Challenges of COVID-19 and Racism. The Journal of pediatrics Ramirez, M. R., Bruce, J. S., Ball, A. J., Gambhir, S., Zabrocka, K., Sahak, O., Dali, S., Jones, K., Chamberlain, L. J. 2020

  View details for DOI 10.1016/j.jpeds.2020.11.048

  View details for PubMedID 33301783

• A comparison of provider perspectives on cultural competency training: A mixed methods study. American journal of surgery Liu, M. M., Miller, M. O., Merrell, S. B., Bruce, J. S., Kin, C., Morris, A. M. 2020

  Abstract

  BACKGROUND: We aimed to identify differences in training among colorectal cancer physicians and advanced practice providers with high and low cultural competency METHODS: Using explanatory sequential mixed methods, we surveyed providers and dichotomized into high and low cultural competency (CC) groups, conducted qualitative interviews, and analyzed verbatim transcripts using deductive and inductive codes to compared findings across groups using a joint display.RESULTS: Fifty-four of 92 providers (59%) responded; 10 respondents from each group (20/36 invited) completed semi-structured interviews about previous CC trainings. Low CC providers' training included explanations of cultural differences that, in practice, improved awareness and utilization of communication tools, but they also desired decision-making tools and cultural exposure. High CC providers' training included action-oriented toolkits. In practice, they admitted failures, improved communication, and attributed patient behaviors to external factors. High CC providers desired performance evaluations.CONCLUSIONS: Behaviorally-oriented CC training offered a robust foundation for culturally competent care.

  View details for DOI 10.1016/j.amjsurg.2020.11.003

  View details for PubMedID 33220937

• "Making It Work": A Preliminary Mixed Methods Study of Rural Trauma Care Access and Resources in New Mexico CUREUS Carroll, A. L., Garcia, D., Cassells, S. J., Bruce, J. S., Merrell, S., Schillinger, E. 2020; 12 (10)

  View details for DOI 10.7759/cureus.11143

  View details for Web of Science ID 000582230400024

• "Making It Work": A Preliminary Mixed Methods Study of Rural Trauma Care Access and Resources in New Mexico. Cureus Carroll, A. L., Garcia, D., Cassells, S. J., Bruce, J. S., Bereknyei Merrell, S., Schillinger, E. 2020; 12 (10): e11143

  Abstract

  Introduction Patients in the rural western United States face challenges accessing trauma and surgical services and are more likely to succumb to their injuries. New Mexico, a rural and medically underresourced state, is a salient space to study these disparities. We examine how travel distance from trauma centers impacts injured patient outcomes and describe care delivery obstacles. Materials and Methods We conducted an explanatory mixed methods study by creating geospatial maps of New Mexico's trauma data, incorporating linear regression analyses on patient outcomes as a function of estimated travel distance from trauma centers. We also conducted qualitative semi-structured interviews with trauma providers to illuminate and provide context for the geospatial findings utilizing a systematic, collaborative, iterative transcript analysis process. We constructed a conceptual framework describing rural trauma care delivery obstacles. Results Geospatial analyses revealed that most New Mexicans face long travel times to trauma centers. Comparing regression analyses using different data sources suggests that solely hospital-derived data may undercount rural trauma deaths. Interviews with 10 providers suggest that elements that may contribute to these findings include on-the-ground resource-based challenges and those related to broader healthcare systems-based issues. Our conceptual framework denotes how these elements collectively may impact rural trauma outcomes and proposes potential solutions. Conclusions In addressing rural patients' needs, healthcare policy decision-makers should ensure that their datasets are comprehensive and inclusive. They must also take into account the particular challenges of underserved rural patients and providers who care for them by eliciting their perspectives, as presented in our conceptual framework.

  View details for DOI 10.7759/cureus.11143

  View details for PubMedID 33251053

  View details for PubMedCentralID PMC7685818

• More to offer than books: stakeholder perceptions of a public library-based meal programme. Public health nutrition De La Cruz, M. M., Phan, K., Bruce, J. S. 2020; 23 (12): 2179-2188

  Abstract

  To examine the perspectives of librarians and staff about Lunch at the Library, a library-based summer meal programme for children. The study examines: (i) motivating factors behind implementing the meal programme; (ii) issues of feasibility; and (iii) perceived programme outcomes.One-on-one semi-structured interviews with library stakeholders (librarians and staff) from a purposeful sample of California libraries.Twenty-two library jurisdictions across California that implemented the Lunch at the Library summer meal programme in 2015 in areas of high financial need.Twenty-five library stakeholders representing twenty-two of the thirty-three Californian library jurisdictions that implemented Lunch at the Library at their sites.Library stakeholders recognised the need for a child meal programme during summer. Despite lack of sufficient resources and personnel, they were motivated to implement the programme not only to fill a community need but also to ensure children at their libraries were primed for learning over the summer. Library stakeholders also perceived the public library's changing role in society as shifting from reference provision to social service provision either directly or by referral.The public library is an ideal place to provide social services because of its accessibility to all. Librarians and library staff are motivated to address the social needs of their communities. This study demonstrates the feasibility of implementing new social programmes at public libraries. Funding to support these programmes would increase the library's capacity to address other community needs.

  View details for DOI 10.1017/S1368980019004336

  View details for PubMedID 32312358

• Opportunities for Supporting Latino Immigrants in Emergency and Ambulatory Care Settings. Journal of community health Lee, J., Bruce, J., Wang, N. E. 2020

  Abstract

  Toughened immigration policies exacerbate barriers to public benefits and health care for immigrants. The objective of this study is to examine the impact of the immigration climate on the utilization of pediatric emergency and ambulatory care services and elucidate ways to best support Latino immigrant families. This is a cross-sectional study involving surveys and interviews with Latino parents (≥18years) in the pediatric emergency department. Forty-five parents completed surveys and 40 were interviewed. We identified two themes on health care utilization: fear of detention and deportation in health care settings, and barriers to pediatric primary care; and two themes on how pediatric providers can best support Latinos: information and guidance on immigration policies, and reassurance and safety during visits. Despite immigration fears, Latino parents continue to seek health care for their children. This highlights the unique access that pediatric providers have to this vulnerable population to address immigration fears and establish trust in the health care system. Health care providers are also perceived as trusted figures from whom Latino families want more information on the latest immigration policies, immigration resources, and education on legal rights during medical visits.

  View details for DOI 10.1007/s10900-020-00889-7

  View details for PubMedID 32700173

• A Clinic-Based School Readiness Coaching Intervention for Low-Income Latino Children: An Intervention Study. Clinical pediatrics Peterson, J. W., Huffman, L. C., Bruce, J., Prata, N., Harley, K. G., Chamberlain, L. J. 2020: 9922820941230

  Abstract

  This intervention study assessed school readiness (SR)-related parent behaviors and perceived barriers for Latino parent-child pairs (N = 149, Mage = 4.5) after a clinic-based SR intervention (n = 74) or standard well-child care (n = 75). Intervention was a 1-hour visit with a community health worker (CHW) to assess child SR, model SR interactions, and provide SR tools and resources. Primary outcomes were parent behaviors and barriers collected by phone questionnaire. Regression analyses revealed that parents in the intervention were more likely to tell their child a story and visit the library in the last week and less likely to report barriers of limited SR knowledge. A brief, SR coaching intervention with a CHW increased SR-related parent behaviors and reduced barriers to SR. Evaluation with school entry data is underway.

  View details for DOI 10.1177/0009922820941230

  View details for PubMedID 32696662

• Stories of success: a qualitative examination of contributors to excellence in school drinking water access. Public health nutrition Cooper, A. Y., Altman, E. n., Hecht, C. E., Bruce, J. n., Patel, A. I. 2020: 1–10

  Abstract

  Drinking water instead of beverages with added sugar can help prevent obesity and cavities and promote overall health. Children spend much of their day in school, where they have variable access to drinking water. In 2010, federal and state law required California public schools to provide free potable water to students in areas where meals are served and/or eaten. The current study aims to identify factors associated with an excellent drinking water culture in schools.A qualitative assessment of barriers and facilitators to providing excellent water quality and access in a purposive sample of California schools. In-depth interviews with key informants were conducted using a snowball sampling approach, after which data were analysed using both inductive and deductive methods.California public elementary, middle/junior and high schools.Knowledgeable individuals involved in initiatives related to school drinking water accessibility, quality or education at each selected school.Thirty-four interviewees participated across fifteen schools. Six themes emerged as prominent facilitators to a school's success in providing excellent water access to students: active and engaged champions, school culture and policy, coordination between groups, community influences, available resources and environmentalism.While policy is an important step for achieving minimum standards, resources and interest in promoting excellence in drinking water access and quality can vary among schools. Ensuring that schools have dedicated staff committed to advancing student health and promoting the benefits of water programs that are more salient to schools could help reduce disparities in drinking water excellence across schools.

  View details for DOI 10.1017/S1368980019003975

  View details for PubMedID 32100660

• School Readiness Coaching in the Pediatric Clinic: Latinx Parent Perspectives. Academic pediatrics Peterson, J. W., Almanzar, N. n., Chamberlain, L. J., Huffman, L. n., Butze, T. n., Marin-Nevarez, P. n., Bruce, J. S. 2020

  Abstract

  Children who enter school developmentally ready for kindergarten are more likely to succeed academically, be healthy and lead productive lives. However, low-income and minority children often enter kindergarten behind their more affluent peers. Pediatric clinics, as trusted family partners, are well positioned to provide school readiness (SR) support.To explore Latinx parent perceptions of a clinic-based SR coaching intervention using qualitative methods. Intervention was a 1-hour visit with an SR coach (bilingual community health worker trained to assess child SR, role model SR skills and provide educational tools and community resources).Qualitative theme analysis of Latinx parent semi-structured interviews completed 6-9 months after SR coaching intervention (June 2016 - February 2017). Parent-child pairs received the SR coaching intervention (N=74), post-intervention interviews (N=50) were completed, audio recorded and transcribed. Iterative team-based coding and inductive thematic analysis of interviews were conducted.Three domains emerged and included the SR coaching model, community SR resources, and parent SR knowledge. Sub-themes included 1) Parents valued the one-to-one SR coaching intervention, were receptive to coach recommendations and believed other parents would benefit from SR coaching; 2) Parents tried new early literacy activities with their child; 3) Despite positive intervention effects, parents lacked a comprehensive understanding of SR.A brief clinic-based SR coaching intervention with a bilingual SR coach was well received by low-income Latinx parents and increased parent SR behaviors. Expanded implementation and further quantitative evaluation using school entry child-specific data are needed to quantify effects.

  View details for DOI 10.1016/j.acap.2020.10.009

  View details for PubMedID 33096288

• Meeting the Needs of Postpartum Women With and Without a Recent Preterm Birth: Perceptions of Maternal Family Planning in Pediatrics. Maternal and child health journal Congdon, J. L., Trope, L. A., Bruce, J. S., Chung, P. J., Dehlendorf, C., Chamberlain, L. J. 2019

  Abstract

  OBJECTIVES: Women face distinct barriers to meeting their reproductive health needs postpartum, especially women who deliver preterm. Pediatric encounters present unique opportunities to address women's family planning, particularly within 18months of a prior pregnancy, when pregnancy has an elevated risk of an adverse outcome, such as preterm birth. To ensure maternal family planning initiatives are designed in a patient-centered manner, we explored perspectives on addressing reproductive health in a pediatric setting among women with and without a recent preterm delivery.METHODS: We conducted semi-structured, qualitative interviews with 41 women (66% delivered preterm). Women who delivered at any gestational age were interviewed at a pediatric primary care clinic. We also interviewed women whose infants were either in a level II intensive care nursery or attending a high-risk infant follow-up clinic, all of whom had delivered preterm. Data were analyzed using team-based coding and theme analysis.RESULTS: While women's preferred timing and setting for addressing peripartum contraception varied, they largely considered pediatric settings to be an acceptable place to discuss family planning. A few women felt family planning fell outside of the pediatric scope or distracted from the child focus. Women discussed various barriers to accessing family planning care postpartum, including circumstances unique to women who delivered preterm.CONCLUSIONS FOR PRACTICE: Family planning interventions in pediatric settings were overall an acceptable approach to reducing barriers to care among our sample of women who predominantly delivered preterm. These exploratory findings justify further investigation to assess their generalizability and to develop maternal family planning interventions for pediatric settings.

  View details for DOI 10.1007/s10995-019-02829-x

  View details for PubMedID 31875305

• Unavoidable Risks: Local Perspectives on Water Contact Behavior and Implications for Schistosomiasis Control in an Agricultural Region of Northern Senegal. The American journal of tropical medicine and hygiene Lund, A. J., Sam, M. M., Sy, A. B., Sow, O. W., Ali, S., Sokolow, S. H., Merrell, S. B., Bruce, J., Jouanard, N., Senghor, S., Riveau, G., Lopez-Carr, D., De Leo, G. A. 2019

  Abstract

  Human schistosomiasis is a snail-borne parasitic disease affecting more than 200 million people worldwide. Direct contact with snail-infested freshwater is the primary route of exposure. Water management infrastructure, including dams and irrigation schemes, expands snail habitat, increasing the risk across the landscape. The Diama Dam, built on the lower basin of the Senegal River to prevent saltwater intrusion and promote year-round agriculture in the drought-prone Sahel, is a paradigmatic case. Since dam completion in 1986, the rural population-whose livelihoods rely mostly on agriculture-has suffered high rates of schistosome infection. The region remains one of the most hyperendemic regions in the world. Because of the convergence between livelihoods and environmental conditions favorable to transmission, schistosomiasis is considered an illustrative case of a disease-driven poverty trap (DDPT). The literature to date on the topic, however, remains largely theoretical. With qualitative data generated from 12 focus groups in four villages, we conducted team-based theme analysis to investigate how perception of schistosomiasis risk and reported preventive behaviors may suggest the presence of a DDPT. Our analysis reveals three key findings: 1) rural villagers understand schistosomiasis risk (i.e., where and when infections occur), 2) accordingly, they adopt some preventive behaviors, but ultimately, 3) exposure persists, because of circumstances characteristic of rural livelihoods. These findings highlight the capacity of local populations to participate actively in schistosomiasis control programs and the limitations of widespread drug treatment campaigns. Interventions that target the environmental reservoir of disease may provide opportunities to reduce exposure while maintaining resource-dependent livelihoods.

  View details for DOI 10.4269/ajtmh.19-0099

  View details for PubMedID 31452497

• Challenges of infertility genetic counseling: Impact on counselors' personal and professional lives JOURNAL OF GENETIC COUNSELING Liker, K., Black, L., Weil, J., Bruce, J., Merrell, S., Bivona, S., Ormond, K. E. 2019; 28 (3): 626–40

  View details for DOI 10.1002/jgc4.1106

  View details for Web of Science ID 000472673100012

• Combating Child Summer Food Insecurity: Examination of a Community-Based Mobile Meal Program. Journal of community health Bruce, J. S., De La Cruz, M. M., Lundberg, K., Vesom, N., Aguayo, J., Merrell, S. B. 2019

  Abstract

  Low-income children's access to meals decreases during the summer months due to losing the benefit of the free and reduced-price lunches they normally receive during the school year. Few studies critically examine community-based approaches to providing summer meals. This mixed methods study examined a mobile meal program implemented in a community with large economic disparities. Parents and caregivers who attended the mobile meal program with a child at one of three sites completed surveys that screened for risk of food insecurity and examined access and utilization of community food resources. Interviews with a representative subsample of English- and Spanish-speaking participants elicited an in-depth understanding of food insecurity in the community and perspectives on the mobile meal program. Surveys (n=284) were completed in English (78%) and Spanish (22%). Participants identified primarily as Asian (32%), Latino/Hispanic (29%), and White (27%), with 26% screening positive for risk of food insecurity within the past 12months. Qualitative interviews (n=36) revealed widespread support for meals served in public settings as they were perceived to be welcoming, fostered social interactions, and helped the community at large. Participants described the high cost of living as a key motivation for participating and cited immigration fears as a barrier to accessing public resources. Findings from this study suggest the importance of innovative community-based approaches to serving hard-to-reach children during the summer.

  View details for DOI 10.1007/s10900-019-00675-0

  View details for PubMedID 31073855

• Challenges of infertility genetic counseling: Impact on counselors' personal and professional lives. Journal of genetic counseling Liker, K., Black, L., Weil, J., Bruce, J., Bereknyei Merrell, S., Bivona, S., Ormond, K. E. 2019

  Abstract

  Infertility genetic counselors (GCs) work with patients struggling to become pregnant who desire genetic testing of embryos and preconception genetic testing or carrier screening. Because personal and professional challenges have not been examined in this relatively new genetic counseling specialty, we investigated the difficulties infertility GCs face in their professional roles. Past and present infertility GCs in patient-facing roles were recruited through the National Society of Genetic Counselors. Purposive sampling ensured participants were diverse in clinical setting, reproductive history, and other demographics. Nineteen participants completed a semi-structured interview, at which time data saturation occurred. Thematic analysis revealed infertility GCs consider their patients more emotionally stressed than patients in other specialties. Infertility GCs relate easily to patients, build long-term patient relationships, and feel invested in the reproductive successes of patients. Participants reported heightened concern for their own fertility, leading to high personal uptake of preconception genetic and fertility tests. Participants described discomfort when counseling while visibly pregnant and reluctance to disclose their own reproductive histories. Further research is needed on the complex interactions of GCs' personal and professional lives. Peer support groups and professional dialogue about the personal effects of the role may be beneficial for infertility GCs.

  View details for PubMedID 30821877

• What Do Clinical Environments Say to Our Patients? A Replicable Model for Creative Advocacy. American journal of public health Steinberg, J. R., Ramphos, E., Bruce, J. S., Chamberlain, L. J. 2018; 108 (11): 1509–10

  View details for PubMedID 30303727

• What Do Clinical Environments Say to Our Patients? A Replicable Model for Creative Advocacy AMERICAN JOURNAL OF PUBLIC HEALTH Steinberg, J. R., Ramphos, E., Bruce, J. S., Chamberlain, L. J. 2018; 108 (11): 1509-1510

  View details for DOI 10.2105/AJPH.2018.304678

  View details for Web of Science ID 000446866300035

• Exploring the Medical and Psychosocial Concerns of Adolescents and Young Adults With Craniofacial Microsomia: A Qualitative Study CLEFT PALATE-CRANIOFACIAL JOURNAL Hamilton, K. V., Ormond, K. E., Moscarello, T., Bruce, J. S., Merrell, S., Chang, K. W., Bernstein, J. A. 2018; 55 (10): 1430–39

  View details for DOI 10.1177/1055665618768542

  View details for Web of Science ID 000446871400011

• Early Childhood Learning and the Pediatrician: A Qualitative Study Among Diverse, Low-Income Caregivers JOURNAL OF DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS Steinberg, J., Bruce, J. S., Marin-Nevarez, P., Phan, K., Merrell, S., Chamberlain, L. J. 2018; 39 (5): 376–86

  View details for DOI 10.1097/DBP.0000000000000564

  View details for Web of Science ID 000441393000004

• Interprofessional Collaboration: A Qualitative Study of Non-Physician Perspectives on Resident Competency JOURNAL OF GENERAL INTERNAL MEDICINE Garth, M., Millet, A., Shearer, E., Stafford, S., Merrell, S., Bruce, J., Schillinger, E., Aaronson, A., Svec, D. 2018; 33 (4): 487–92

  Abstract

  The Association of American Medical Colleges (AAMC) includes the ability to collaborate in an interprofessional team as a core professional activity that trainees should be able to complete on day 1 of residency (Med Sci Educ. 26:797-800, 2016). The training that medical students require in order to achieve this competency, however, is not well established (Med Sci Educ. 26:457-61, 2016), and few studies have examined non-physician healthcare professionals' perspectives regarding resident physicians' interprofessional skills.This study aims to describe non-physicians' views on barriers to collaboration with physicians, as well as factors that contribute to good collaborative relationships.Nurses, social workers, case managers, dietitians, rehabilitation therapists, and pharmacists at one academic medical center, largely working in the inpatient setting.A qualitative study design was employed. Data were collected from individual interviews and focus groups comprising non-physician healthcare professionals.Knowledge gaps identified as impeding interprofessional collaboration included inadequate understanding of current roles, potential roles, and processes for non-physician healthcare professionals. Specific physician behaviors that were identified as contributing to good collaborative relationships included mutual support such as backing up other team members and prioritizing multidisciplinary rounds, and communication including keeping team members informed, asking for their input, physicians explaining their rationale, and practicing joint problem-solving with non-physicians.Discussion of how physician trainees can best learn to collaborate as members of an interprofessional team must include non-physician perspectives. Training designed to provide medical students and residents with a better understanding of non-physician roles and to enhance mutual support and communication skills may be critical in achieving the AAMC's goals of making physicians effective members of interprofessional teams, and thus improving patient-centered care. We hope that medical educators will include these areas identified as important by non-physicians in targeted team training for their learners.

  View details for PubMedID 29204972

  View details for PubMedCentralID PMC5880757

• Early Childhood Learning and the Pediatrician: A Qualitative Study Among Diverse, Low-Income Caregivers. Journal of developmental and behavioral pediatrics : JDBP Steinberg, J. R., Bruce, J. S., Marin-Nevarez, P., Phan, K., Merrell, S. B., Chamberlain, L. J. 2018

  Abstract

  OBJECTIVE: School readiness by kindergarten entry is associated with increased high school graduation, decreased juvenile arrest, and better long-term health. Inadequate early childhood learning (ECL) disproportionately affects low-income children. Pediatricians have near-universal access to children younger than 5 years but remain an underused ECL resource. This study examined caregivers' perceptions of ECL, the role of the pediatrician and pediatric office, and the use of community-based ECL resources among diverse, low-income caregivers whose children were not enrolled in preschool.METHODS: Using community-engaged strategies, caregivers were recruited to participate in in-depth focus groups (FGs). Demographic and FG data were collected in English, Spanish, and Vietnamese. Qualitative data were analyzed with iterative transcript-based coding and theme analysis.RESULTS: From June 2015 to August 2015, 69 low-income mothers (n = 46), fathers (n = 8), and grandparents (n = 15) from African-American (33%), Latino (32%), and Vietnamese (35%) communities participated in 12 FGs. Caregivers across groups wanted pediatricians to act as ECL experts and to provide ECL services. Caregivers valued ECL, especially when delivered by trusted sources. Utilization and perception of community ECL resources varied among groups. The greatest variation included different preferences for resource setting, accessibility, and acceptability, especially cultural acceptability. Each individual and groups' unique, and occasionally adverse, experiences and financial and logistical considerations informed ECL preferences.CONCLUSION: This exploratory study brings forth diverse caregivers' perspectives regarding the role of pediatricians in ECL and their desire for pediatricians to be an access point for high-quality, affordable ECL services. Caregivers' preferences regarding ECL programming may inform clinic-based pediatric ECL programming.

  View details for PubMedID 29538187

• Building a Novel Health Curriculum for Survivors of Intimate Partner Violence Residing at a Transitional Housing Program VIOLENCE AGAINST WOMEN Ragavan, M., Bruce, J., Bair-Merritt, M., Lucha, S., Maya-Silva, J., Stebbins, E., Chamberlain, L. 2018; 24 (3): 266–85

  Abstract

  We used a community-based participatory research approach to develop, implement, and evaluate one of the first health curricula for female intimate partner violence (IPV) survivors residing at a transitional housing program. The curriculum comprised 12 workshops that were developed based on the survivors' experiences, needs, and interests. Evaluation participants included 20 of the 37 women who attended at least one workshop, 12 workshop facilitators, and two housing center staff. Participants found the curriculum to be engaging, interactive, and helpful in building a supportive community. Suggestions for curricular improvement as well as opportunities for further research and curricular development are discussed.

  View details for PubMedID 29332505

• A Qualitative Study on Inappropriate ICU Admissions: One Step Closer to Preventing Inappropriate ICU Care Harman, S., Marks, N., Kruse, K., Bruce, J., Magnus, D. ELSEVIER SCIENCE INC. 2018: 686

  View details for Web of Science ID 000425399300304

• Parental Attitudes, Behaviors, and Barriers to School Readiness among Parents of Low-Income Latino Children INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH Peterson, J., Bruce, J., Patel, N., Chamberlain, L. J. 2018; 15 (2)

  Abstract

  We sought to explore parental attitudes, behaviors, and barriers regarding school readiness in a county clinic serving low income, Latino children. Between December 2013-September 2014, we conducted a cross sectional survey of parents during 3-6 years well-child appointments about school readiness (SR) across: (1) attitudes/behaviors; (2) barriers; and (3) awareness; and (4) use of local resources. Most parents (n = 210, response rate 95.6%) find it very important/important for their child to know specific skills prior to school: take turns and share (98.5%), use a pencil and count (97.6%), know letters (99.1%), colors (97.1%), and shapes (96.1%). Over 80% of parents find education important and engage in positive SR behaviors: singing, practicing letters, or reading. Major barriers to SR were lack of knowledge for kindergarten readiness, language barriers, access to books at home, constraints on nightly reading, difficulty completing school forms, and limited free time with child. Awareness of local resources such as preschool programs was higher than actual utilization. These low-income, Latino parents value SR but lack knowledge to prepare their child for school and underutilize community resources such as free preschool programs. Pediatricians are uniquely positioned to address these needs, but more evidence-based interventions are needed.

  View details for DOI 10.3390/ijerph15020188

  View details for Web of Science ID 000426721400013

  View details for PubMedID 29364154

  View details for PubMedCentralID PMC5857047

• Exploring the Medical and Psychosocial Concerns of Adolescents and Young Adults With Craniofacial Microsomia: A Qualitative Study. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association Hamilton, K. V., Ormond, K. E., Moscarello, T. n., Bruce, J. S., Bereknyei Merrell, S. n., Chang, K. W., Bernstein, J. A. 2018: 1055665618768542

  Abstract

  This study explores the experiences of adolescents and young adults with craniofacial microsomia, including the impact of growing up with this craniofacial condition on daily life and sense of self. The results may guide future research on optimally supporting individuals with craniofacial microsomia during this critical life phase.Participants were recruited through a craniofacial center, online patient support groups, and social media sites. Eleven individual semistructured interviews with participants between 12 and 22 years old were conducted by a single interviewer, transcribed, iteratively coded, and thematically analyzed.Five themes were evident in the data: (1) impact on personal growth and character development, (2) negative psychosocial impact, (3) deciding to hide or reveal the condition, (4) desire to make personal surgical decisions, and (5) struggles with hearing loss.We identified both medical and psychosocial concerns prevalent among adolescents with craniofacial microsomia. Although adolescents with craniofacial microsomia exhibit considerable resilience, the challenges they face impact their sense of self and should be addressed through psychosocial support and counseling. Further research should investigate the potential benefit of the wider use of hearing aids, as well as the involvement of patients in decision-making about reconstructive ear surgery.

  View details for PubMedID 29634364

• INAPPROPRIATE ICU ADMISSIONS: ONE STEP CLOSER TO ADDRESSING INAPPROPRIATE ICU CARE FOR PATIENTS Marks, R., Kruse, K., Magnus, D., Bruce, J., Harman, S. LIPPINCOTT WILLIAMS & WILKINS. 2018: 229

  View details for DOI 10.1097/01.ccm.0000528506.64775.d8

  View details for Web of Science ID 000436794300452

• Information-Seeking about Anxiety and Perceptions about Technology to Teach Coping Skills in Older Veterans CLINICAL GERONTOLOGIST Zapata, A. L., Beaudreau, S. A., O'Hara, R., Merrell, S., Bruce, J., Garrison-Diehn, C., Gould, C. E. 2018; 41 (4): 346–56

  Abstract

  We sought to learn where older veterans seek information about anxiety and coping. Due to increasing use of technology in health care, we also explored benefits and barriers of using technology to teach coping skills.Twenty veterans (mean age = 69.5 years, SD = 7.3) participated in semi-structured interviews in which we inquired about where they seek information about anxiety. We explored quantitative and qualitative differences for veterans with high versus low anxiety. In follow-up focus groups, we examined opinions about learning coping skills using technology.Though veterans primarily named health care professionals as sources of information about anxiety, online searches and reading books were frequently mentioned. Reported benefits of using technology were convenience and standardized instruction of coping skills. Barriers included lack of interaction and frustration with technology usability.Older veterans use multiple sources, heavily rely on interpersonal sources (e.g., professionals, friends), and employ varied search strategies regarding how to cope with anxiety. Using technology to teach coping skills was generally acceptable to older veterans.Health care professionals could guide patients towards credible online and book sources. Providing instruction about using technology may help older adults use technology to learn coping skills.

  View details for PubMedID 28967837

• Promoting student case creation to enhance instruction of clinical reasoning skills: a pilot feasibility study Advances in Medical Education and Practice Chandrasekar, H., Gesundheit, N., Nevins, A. B., Pompei, P., Bruce, J., Bereknyei Merrell, S. 2018; 2018 (9): 249-257

  Abstract

  It is a common educational practice for medical students to engage in case-based learning (CBL) exercises by working through clinical cases that have been developed by faculty. While such faculty-developed exercises have educational strengths, there are at least two major drawbacks to learning by this method: the number and diversity of cases is often limited; and students decrease their engagement with CBL cases as they grow accustomed to the teaching method. We sought to explore whether student case creation can address both of these limitations. We also compared student case creation to traditional clinical reasoning sessions in regard to tutorial group effectiveness, perceived gains in clinical reasoning, and quality of student-faculty interaction.Ten first-year medical students participated in a feasibility study wherein they worked in small groups to develop their own patient case around a preassigned diagnosis. Faculty provided feedback on case quality afterwards. Students completed pre- and post-self-assessment surveys. Students and faculty also participated in separate focus groups to compare their case creation experience to traditional CBL sessions.Students reported high levels of team engagement and peer learning, as well as increased ownership over case content and understanding of clinical reasoning nuances. However, students also reported decreases in student-faculty interaction and the use of visual aids (P < 0.05).The results of our feasibility study suggest that student-generated cases can be a valuable adjunct to traditional clinical reasoning instruction by increasing content ownership, encouraging student-directed learning, and providing opportunities to explore clinical nuances. However, these gains may reduce student-faculty interaction. Future studies may be able to identify an improved model of faculty participation, the ideal timing for incorporation of this method in a medical curriculum, and a more rigorous assessment of the impact of student case creation on the development of clinical reasoning skills.

  View details for DOI 10.2147/AMEP.S155481

  View details for PubMedCentralID PMC5903478

• Commercial Sexual Exploitation and Sex Trafficking of Children and Adolescents: A Narrative Review ACADEMIC PEDIATRICS Barnert, E., Iqbal, Z., Bruce, J., Anoshiravani, A., Kolhatkar, G., Greenbaum, J. 2017; 17 (8): 825–29

  Abstract

  Commercial sexual exploitation and sex trafficking of children and adolescents represent a severe form of child abuse and an important pediatric health concern. Youth who are commercially sexually exploited have a constellation of clinical risk factors and high rates of unmet physical and mental health needs, including conditions that directly result from their victimization. Common physical health needs among commercially sexually exploited children and adolescents include violence-related injuries, pregnancy, sexually transmitted infections, and other acute infections. Common mental health conditions include substance use disorders, post-traumatic stress disorder, depression and suicidality, and anxiety. The existing literature indicates that trauma-informed approaches to the care of commercially sexually exploited youth are recommended in all aspects of their health care delivery. Additionally, medical education that attunes providers to identify and appropriately respond to the unique needs of this highly vulnerable group of children and adolescents is needed. The available research on commercial sexual exploitation and sex trafficking of children and adolescents remains fairly limited, yet is expanding rapidly. Especially relevant to the field of pediatrics, future research to guide health professionals in how best to identify and care for commercially sexually exploited children and adolescents in the clinical setting signifies a key gap in the extant literature and an important opportunity for future study.

  View details for Web of Science ID 000414622300007

  View details for PubMedID 28797913

  View details for PubMedCentralID PMC5673585

• The Health of Women and Children After Surviving Intimate Partner Violence VIOLENCE AGAINST WOMEN Ragavan, M., Bruce, J., Lucha, S., Jayaraman, T., Stein, H., Chamberlain, L. 2017; 23 (10): 1205–27

  View details for DOI 10.1177/1077801216656833

  View details for Web of Science ID 000407075800003

• Development of a video-delivered relaxation treatment of late-life anxiety for veterans. International psychogeriatrics Gould, C. E., Zapata, A. M., Bruce, J., Bereknyei Merrell, S., Wetherell, J. L., O'Hara, R., Kuhn, E., Goldstein, M. K., Beaudreau, S. A. 2017: 1-13

  Abstract

  Behavioral treatments reduce anxiety, yet many older adults may not have access to these efficacious treatments. To address this need, we developed and evaluated the feasibility and acceptability of a video-delivered anxiety treatment for older Veterans. This treatment program, BREATHE (Breathing, Relaxation, and Education for Anxiety Treatment in the Home Environment), combines psychoeducation, diaphragmatic breathing, and progressive muscle relaxation training with engagement in activities.A mixed methods concurrent study design was used to examine the clarity of the treatment videos. We conducted semi-structured interviews with 20 Veterans (M age = 69.5, SD = 7.3 years; 55% White, Non-Hispanic) and collected ratings of video clarity.Quantitative ratings revealed that 100% of participants generally or definitely could follow breathing and relaxation video instructions. Qualitative findings, however, demonstrated more variability in the extent to which each video segment was clear. Participants identified both immediate benefits and motivation challenges associated with a video-delivered treatment. Participants suggested that some patients may need encouragement, whereas others need face-to-face therapy.Quantitative ratings of video clarity and qualitative findings highlight the feasibility of a video-delivered treatment for older Veterans with anxiety. Our findings demonstrate the importance of ensuring patients can follow instructions provided in self-directed treatments and the role that an iterative testing process has in addressing these issues. Next steps include testing the treatment videos with older Veterans with anxiety disorders.

  View details for DOI 10.1017/S1041610217000928

  View details for PubMedID 28592349

• Lunch at the library: examination of a community-based approach to addressing summer food insecurity. Public health nutrition Bruce, J. S., De La Cruz, M. M., Moreno, G., Chamberlain, L. J. 2017: 1-10

  Abstract

  To examine a library-based approach to addressing food insecurity through a child and adult summer meal programme. The study examines: (i) risk of household food insecurity among participants; (ii) perspectives on the library meal programme; and (iii) barriers to utilizing other community food resources.Quantitative surveys with adult participants and qualitative semi-structured interviews with a sub-sample of adult participants.Ten libraries using public and private funding to serve meals to children and adults for six to eight weeks in low-income Silicon Valley communities (California, USA) during summer 2015.Adult survey participants (≥18 years) were recruited to obtain maximum capture, while a sub-sample of interview participants was recruited through maximum variation purposeful sampling.Survey participants (n 161) were largely Latino (71 %) and Asian (23 %). Forty-one per cent of participants screened positive for risk of food insecurity in the past 12 months. A sub-sample of programme participants engaged in qualitative interviews (n 67). Interviewees reported appreciating the library's child enrichment programmes, resources, and open and welcoming atmosphere. Provision of adult meals was described as building community among library patrons, neighbours and staff. Participants emphasized lack of awareness, misinformation about programmes, structural barriers (i.e. transportation), immigration fears and stigma as barriers to utilizing community food resources.Food insecurity remains high in our study population. Public libraries are ideal locations for community-based meal programmes due to their welcoming and stigma-free environment. Libraries are well positioned to link individuals to other social services given their reputation as trusted community organizations.

  View details for DOI 10.1017/S1368980017000258

  View details for PubMedID 28318465

• Patient-Centered Care Challenges and Surprises: Through the Clerkship Students' Eyes. Family medicine Boggiano, V. L., Wu, Y., Bruce, J. S., Merrell, S. B., Schillinger, E. 2017; 49 (1): 57-61

  Abstract

  The patient-centered care model for health care delivery encourages medical providers to respect patients' preferences and give patients more autonomy over their health care decisions. This approach has gained importance within US medical school curricula. Yet, little is known about student perspectives on both patient-centered care and the benefits and challenges that lie therein. This manuscript explores the greatest impediments to, as well as the benefits from, student engagement in patient-centered care from the perspectives of students participating in their family medicine outpatient clerkship.Clerkship students on their core family medicine clerkship at Stanford University School of Medicine were provided the following open-ended prompt: "Describe a patient-centered care challenge or surprise in the family medicine core clerkship." Free-text responses were collected and analyzed using content and thematic analysis.A total of 326 responses from 216 students were analyzed for frequency and patient-centered themes. Nine final themes emerged and were grouped into three domains: student definitions of patient-centered care, patient-centered care impact on patients, and patient-centered care impact on medical professionals.Our study suggests that students find the patient-centered care model for health care delivery to be challenging but worthwhile. We highlight that students find communication with patients in a patient-centered manner challenging and discuss the need for improved medical education about patient-centered care in order to better prepare students to implement the model in a variety of psychosocial and medical contexts.

  View details for PubMedID 28166582

• Underlying mechanisms of mistreatment in the surgical learning environment: A thematic analysis of medical student perceptions. American journal of surgery Brandford, E. n., Hasty, B. n., Bruce, J. S., Bereknyei Merrell, S. n., Shipper, E. S., Lin, D. T., Lau, J. N. 2017

  Abstract

  Medical students experience more psychological distress than the general population. One contributing factor is mistreatment. This study aims to understand the mechanisms of mistreatment as perceived by medical students.Students completed anonymous surveys during the first and last didactic session of their surgery clerkship in which they defined and gave examples of mistreatment. Team-based thematic analysis was performed on responses.Between January 2014 and June 2016, 240 students participated in the surgery clerkship. Eighty-nine percent of students completed a survey. Themes observed included (1) Obstruction of Students' Learning, (2) Exploitation of Student Vulnerability, (3) Exclusion from the Medical Team, and (4) Contextual Amplifiers of Mistreatment Severity.The themes observed in this study improve our understanding of the students' perspective on mistreatment as it relates to their role in the clinical learning context, which can serve as a starting point for interventions that ultimately improve students' experiences in the clinical setting.

  View details for PubMedID 29167023

• Patient-Centered Care Challenges and Surprises FAMILY MEDICINE Boggiano, V. L., Wu, Y., Bruce, J. S., Merrell, S. B., Schillinger, E. 2017; 49 (1): 57-61

  Abstract

  The patient-centered care model for health care delivery encourages medical providers to respect patients' preferences and give patients more autonomy over their health care decisions. This approach has gained importance within US medical school curricula. Yet, little is known about student perspectives on both patient-centered care and the benefits and challenges that lie therein. This manuscript explores the greatest impediments to, as well as the benefits from, student engagement in patient-centered care from the perspectives of students participating in their family medicine outpatient clerkship.Clerkship students on their core family medicine clerkship at Stanford University School of Medicine were provided the following open-ended prompt: "Describe a patient-centered care challenge or surprise in the family medicine core clerkship." Free-text responses were collected and analyzed using content and thematic analysis.A total of 326 responses from 216 students were analyzed for frequency and patient-centered themes. Nine final themes emerged and were grouped into three domains: student definitions of patient-centered care, patient-centered care impact on patients, and patient-centered care impact on medical professionals.Our study suggests that students find the patient-centered care model for health care delivery to be challenging but worthwhile. We highlight that students find communication with patients in a patient-centered manner challenging and discuss the need for improved medical education about patient-centered care in order to better prepare students to implement the model in a variety of psychosocial and medical contexts.

  View details for Web of Science ID 000397087700010

• Building a Novel Health Curriculum for Survivors of Intimate Partner Violence Residing at a Transitional Housing Program Violence Against Women Ragavan, M., Bruce, J. S., Bair-Merritt, M., Lucha, S., Maya-Silva, J., Stebbins, E., Chamberlain, L. J. 2017; 1 (20)
• Health Education for Women and Children: A Community-Engaged Mutual Learning Curriculum for Health Trainees. MedEdPORTAL : the journal of teaching and learning resources Ragavan, M., Karpel, H., Bogetz, A., Lucha, S., Bruce, J. 2016; 12: 10492

  Abstract

  Intimate partner violence (IPV) affects the physical and psychological health of survivors and their children; however, to our knowledge, no comprehensive health curriculum exists for this population. As a partnership between a transitional housing program (THP) and an academic medical center, we developed a health education curriculum for female IPV survivors using the principles of community-based participatory research (CBPR).After partnering with a community-based organization, and recruiting participants (IPV survivors), the curriculum is then taught by health trainees. The materials needed to facilitate the 10 workshops are provided and include: a facilitator's guide; workshop materials, including PowerPoint slides and handouts; a training guide for a community partner to teach facilitators about IPV; a sample focus group guide for curricular evaluation that aligns with CBPR methodologies; a sample time line for curricular implementation; and CBPR resources.The curriculum was implemented for two 9-month periods between September 2014 and June 2016. During the first session, 80% of women attended at least one workshop and during the second session, 65% of women did the same. Participants and staff at the THP found the curriculum engaging and requested that it be implemented yearly.The community-academic partnership offered prehealth and health trainees the opportunity to learn effective methods of delivering health education and to understand some of the challenges associated with surviving IPV. Such education can be provided to trainees at any stage and across multiple specialties (e.g., medical, nursing, public health, or social work). There is potential to replicate this mutual learning curriculum in a wide variety of other settings serving mothers and children.

  View details for DOI 10.15766/mep_2374-8265.10492

  View details for PubMedID 30984834

  View details for PubMedCentralID PMC6440431

• Finding the Words: Medical Students' Reflections on Communication Challenges in Clinic FAMILY MEDICINE Braverman, G., Merrell, S. B., Bruce, J. S., Makoul, G., Schillinger, E. 2016; 48 (10): 775-783

  Abstract

  Interpersonal communication is essential to providing excellent patient care and requires ongoing development. Although aspects of medical student interpersonal communication may degrade throughout career progression, it is unknown what specific elements pose challenges. We aimed to characterize clerkship students' perspectives on communication challenges in the outpatient setting to help inform curricular development.Third-year medical students in a required family medicine clerkship were asked to describe a communication challenge they encountered. Open-ended written responses were collected through a mandatory post-clerkship survey. Responses were qualitatively coded using an a priori framework for teaching and assessing communication skills (The SEGUE Framework for Teaching and Assessing Communication Skills) with data-derived additions to the framework, followed by a team-based thematic analysis.We collected 799 reflections written by 518 students from 2007-2014. Three dominant themes emerged from the analysis: challenges with (1) effectively exchanging information with patients, (2) managing emotional aspects of the patient encounter, and (3) negotiating terms of the encounter.Communication curricula focus on content and process of the medical interview, but insufficient time and energy are devoted to psychosocial factors, including aspects of the encounter that are emotionally charged or conflicting. While gaps in students' communication skillsets may be anticipated or observed by educators, this study offers an analysis of students' own perceptions of the challenges they face.

  View details for Web of Science ID 000387121300004

  View details for PubMedID 27875600

• The Health of Women and Children After Surviving Intimate Partner Violence. Violence against women Ragavan, M., Bruce, J., Lucha, S., Jayaraman, T., Stein, H., Chamberlain, L. 2016

  Abstract

  Few studies have explored the perspectives of survivors of intimate partner violence (IPV) regarding their health and their children's health, their experiences accessing and utilizing health care, and health initiatives that would best serve their families' needs. We facilitated focus groups with female IPV survivors and adolescents who witnessed IPV. Women described their health and their children's health as poor and reported challenges with health care utilization, whereas teenagers generally perceived their health as typical for their age. Participants requested health education workshops, community resources, and social support. This study lays the foundation for further research and the development of health initiatives.

  View details for PubMedID 27411720

• Sexual and reproductive health policies for foster youth in California: A qualitative study of child welfare professionals' experiences and perceptions of policies CHILDREN AND YOUTH SERVICES REVIEW Bruce, J. S. 2016; 61: 184-200

  View details for DOI 10.1016/j.childyouth.2015.12.016

  View details for Web of Science ID 000370458500023

• Sexual and reproductive health policies for foster youth in California: A qualitative study of child welfare professionals' experiences and perceptions of policies Children and Youth Services Review Bruce, J. S. 2016; 61: 184–200
• In Their Own Voices: The Reproductive Health Care Experiences of Detained Adolescent Girls WOMENS HEALTH ISSUES Johnston, E. E., Argueza, B. R., Graham, C., Bruce, J. S., Chamberlain, L. J., Anoshiravani, A. 2016; 26 (1): 48-54

  Abstract

  Adolescent girls involved with the juvenile justice system have higher rates of sexually transmitted infections and pregnancy than their nondetained peers. Although they may receive reproductive health care while detained, following clinician recommendations and accessing services in the community can be challenging.This study aimed to determine the barriers this population faces 1) accessing reproductive health care and 2)following the recommendations they receive when they are in the community.Adolescent girls at a juvenile detention facility completed online surveys about their demographics and sexual health behaviors. A subsequent semistructured interview assessed their experiences with reproductive health care services.Twenty-seven girls aged 14 to 19 were interviewed. The majority (86%) self-reported as Latina or Hispanic. The average age of sexual debut was 13.8 years. The major interview themes were 1) personal priorities and motivations affect decision making, 2) powerful external voices influence reproductive health choices, 3) accessing services “on the run” is particularly challenging, and 4) detention represents an opportunity for intervention and change.Adolescent girls who are detained within the juvenile justice system face reproductive health challenges that vary with their life circumstances. They frequently have priorities, external voices, and situations that influence their decisions. Clinicians who care for these young women are in a unique position to address their health needs. Eliciting girls’ goals, beliefs, and influences through motivational interviewing, as well as developing targeted interventions based on their unique experiences, may be particularly helpful for this population.

  View details for DOI 10.1016/j.whi.2015.09.009

  View details for Web of Science ID 000368262500011

• Understanding Parent Perspectives Concerning Adolescents' Online Access to Personal Health Information. Journal of participatory medicine Gaskin, G. L., Bruce, J., Anoshiravani, A. 2016; 8

  Abstract

  Although today's youth are interested in using the internet to access and manage information related to their health, little information exists about parental attitudes towards the release of health information to adolescents.Structured interviews were conducted with the parents of 83 adolescents detained at a large Northern California juvenile detention facility to examine parental perceptions toward allowing their children online access to their own health information.The majority of parents interviewed (70%) wanted their children to have online access to their own health information. Seventy-nine percent of these parents were also comfortable allowing their children to choose with whom they would share this information.This study is one of the first to examine parental attitudes towards providing adolescents access to their own health information, and the first among parents of underserved youth. This study demonstrates that parents may be quite supportive of allowing their adolescent children to have secure online access to their own health information.

  View details for PubMedID 27595043

• Attitudes Toward Smoking Cessation Among Sheltered Homeless Parents JOURNAL OF COMMUNITY HEALTH Stewart, H. C., Stevenson, T. N., Bruce, J. S., Greenberg, B., Chamberlain, L. J. 2015; 40 (6): 1140-1148

  Abstract

  The prevalence of smoking among homeless adults is approximately 70 %. Cessation programs designed for family shelters should be a high priority given the dangers cigarette smoke poses to children. However, the unique nature of smoking in the family shelter setting remains unstudied. We aimed to assess attitudes toward smoking cessation, and unique barriers and motivators among homeless parents living in family shelters in Northern California. Six focus groups and one interview were conducted (N = 33, ages 23-54). The focus groups and interviews were audiorecorded, transcribed verbatim, and a representative team performed qualitative theme analysis. Eight males and 25 females participated. The following major themes emerged: (1) Most participants intended to quit eventually, citing concern for their children as their primary motivation. (2) Significant barriers to quitting included the ubiquity of cigarette smoking, its central role in social interactions in the family shelter setting, and its importance as a coping mechanism. (3) Participants expressed interest in quitting "cold turkey" and in e-cigarettes, but were skeptical of the patch and pharmacotherapy. (4) Feelings were mixed regarding whether individual, group or family counseling would be most effective. Homeless parents may be uniquely motivated to quit because of their children, but still face significant shelter-based social and environmental barriers to quitting. Successful cessation programs in family shelters must be designed with the unique motivations and barriers of this population in mind.

  View details for DOI 10.1007/s10900-015-0040-2

  View details for Web of Science ID 000363978000012

  View details for PubMedID 25980523

• Attitudes Toward Smoking Cessation Among Sheltered Homeless Parents Journal of community health Stewart, H. C., Stevenson, T. N., Bruce, J. S., Greenberg, B., Chamberlain, L. J. 2015: 1-9

  View details for DOI 10.1007/s10900-015-0040-2

• In Their Own Voices: The Reproductive Health Care Experiences of Detained Adolescent Girls Women's Health Issues Johnston, E. E., Argueza, B. R., Graham, C., Bruce, J. S., Chamberlain, L. J., Anoshiravani, A. 2015; 26 (1)

  View details for DOI 10.1016/j.whi.2015.09.009

• Asthma, tobacco smoke and the indoor environment: a qualitative study of sheltered homeless families JOURNAL OF ASTHMA Buu, M. C., Carter, L., Bruce, J. S., Baca, E. A., Greenberg, B., Chamberlain, L. J. 2014; 51 (2): 142-148

  Abstract

  Asthma is common in homeless children with an incidence of 28-40%. There are few published studies investigating asthma in homeless children. This study examines the perspectives of both caregivers and shelter staff regarding challenges and opportunities of caring for children with asthma.A focus group of sheltered parents (n = 10) with children who have asthma was conducted to identify barriers to optimal asthma management. Key informant interviews (n = 6) were conducted with shelter staff to discuss the shelter systems and policies to address childhood asthma. Data were audio-recorded and transcribed. A representative analysis team performed qualitative theme analysis.Key themes across 5 domains were identified: asthma education, access to asthma medication and equipment, asthma action plans, structural barriers to asthma management and environmental triggers. Parents identified multiple asthma triggers present in the shelter environment but cited lack of control as a barrier to remediation. Shelter staff desired elimination of asthma triggers but refer to the lack of resources as the primary barrier. Shelter staff favored a smoking ban on shelter property but named challenges to policy implementation. Both parents and staff identified asthma education and increased access to medications would be helpful.Policies to reduce environmental exposures, such as a smoking ban, to asthma triggers has the potential to improve the health of sheltered children with asthma.

  View details for DOI 10.3109/02770903.2013.857682

  View details for Web of Science ID 000331908900005

  View details for PubMedID 24147583

• A Multi-Institutional Medical Educational Collaborative: Advocacy Training in California Pediatric Residency Programs ACADEMIC MEDICINE Chamberlain, L. J., Wu, S., Lewis, G., Graff, N., Javier, J. R., Park, J. S., Johnson, C. L., Woods, S. D., Patel, M., Wong, D., Blaschke, G. S., Lerner, M., Kuo, A. K. 2013; 88 (3): 314-321

  Abstract

  Educational collaboratives offer a promising approach to disseminate educational resources and provide faculty development to advance residents' training, especially in areas of novel curricular content; however, their impact has not been clearly described. Advocacy training is a recently mandated requirement of the Accreditation Council for Graduate Medical Education that many programs struggle to meet.The authors describe the formation (in 2007) and impact (from 2008 to 2010) of 13 California pediatric residency programs working in an educational collaboration ("the Collaborative") to improve advocacy training. The Collaborative defined an overarching mission, assessed the needs of the programs, and mapped their strengths. The infrastructure required to build the collaboration among programs included a social networking site, frequent conference calls, and face-to-face semiannual meetings. An evaluation of the Collaborative's activities showed that programs demonstrated increased uptake of curricular components and an increase in advocacy activities. The themes extracted from semistructured interviews of lead faculty at each program revealed that the Collaborative (1) reduced faculty isolation, increased motivation, and strengthened faculty academic development, (2) enhanced identification of curricular areas of weakness and provided curricular development from new resources, (3) helped to address barriers of limited resident time and program resources, and (4) sustained the Collaborative's impact even after formal funding of the program had ceased through curricular enhancement, the need for further resources, and a shared desire to expand the collaborative network.

  View details for DOI 10.1097/ACM.0b013e3182806291

  View details for PubMedID 23348081

• Global Health Training in Pediatric Residency: A Qualitative Analysis of Faculty Director Insights ACADEMIC PEDIATRICS Eneriz-Wiemer, M., Nelson, B. D., Bruce, J., Chamberlain, L. J. 2012; 12 (3): 238-244

  Abstract

  Interest and participation in global health (GH) has been growing rapidly among pediatric residents. Residency programs are responding by establishing formal GH programs. We sought to define key insights in GH education from pediatric residency programs with formal GH tracks.Seven model pediatric residency programs with formal GH training were identified in 2007. Faculty directors representing 6 of these programs participated in expert interviews assessing 6 categories of questions about GH tracks: understanding how GH tracks establish partnerships with global sites; defining organizational and financing structure of GH tracks; describing resident curriculum and pre-trip preparation; describing clinical experiences of residents in GH tracks; defining evaluation of residents and GH tracks; and defining factors that affect development and ongoing implementation of GH tracks. Data were analyzed using qualitative methodology.All programs relied on faculty relationships to establish dynamic partnerships with global sites. All programs acknowledged resident burden on GH partners. Strategies to alleviate burden included improving resident supervision and providing varying models of GH curricula and pre-trip preparation, generally based on core residency training competencies. Support and funding for GH programs are minimal and variable. Resident experiences included volunteer patient care, teaching, and research. Commitment of experienced faculty and support from institutional leadership facilitated implementation of GH programs.Directors of 6 model GH programs within pediatric residencies provided insights that inform others who want to establish successful GH partnerships and resident training that will prepare trainees to meet global child health needs.

  View details for Web of Science ID 000304212400014

  View details for PubMedID 22503444

• Health, Occupational and Environmental Risks of Emancipated Migrant Farmworker Youth JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Peoples, J. D., Bishop, J., Barrera, B., Lamas, O., Dunlap, J. L., Gonzalez, P. A., Horwitz, S. M., Chamberlain, L. J. 2010; 21 (4): 1215-1226

  Abstract

  This study examines the perceptions of health, health seeking behavior, access to information and resources, work related hazards, substance abuse, and social support of emancipated migrant youth (EMY) who come to the United States without their families to work.Semi-structured interviews were performed with EMY living without their families in Santa Clara County, California. Interviews were digitally recorded in Spanish, transcribed, translated into English, and analyzed by a five-person analysis team.Eleven interviews were conducted with 29 participants. Work was identified as the overarching priority of the EMY Their greatest concern was becoming sick and unable to work. They described their work environment as demanding and stressful, but felt obliged to work regardless of conditions. Alcohol and drug abuse were reported as prevalent problems.Emancipated migrant youth are a vulnerable population who have significant occupational stress, hazardous environmental exposures, social isolation, and drug/alcohol abuse.

  View details for Web of Science ID 000283622700012

  View details for PubMedID 21099073

• Universal health care coverage for children: Impact on pediatric health care providers JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Chamberlain, L. J., Hughes, D. C., Bishop, J. S., Matsuda, D. H., Sassoubre, L. 2005; 16 (4): 622-633

  Abstract

  A Northern California county expanded health coverage to cover nearly all children in the state through a new insurance program. In two years, 75,500 children entered a health care system near capacity. We hypothesized that the influx of thousands of previously uninsured children into the health system would affect providers in many ways. This cross-sectional study sought to investigate how this influx affected provider practices, job satisfaction, access to specialists, and overarching views about the program. Qualitative analyses of expert interviews were performed. Providers reported improved access to health care, specialists, and medications for patients. They cited increased job satisfaction for providers due to fewer limits on care, improved referral process, and decreased patient family financial stress. Providers noted the persistence of long appointment wait times for specialist care. After moving to near universal coverage, safety net providers described increased job satisfaction. Because this study examined safety-net providers, future research requires a more representative sample of providers.

  View details for Web of Science ID 000233779500005

  View details for PubMedID 16311488