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Department of Family and Community Medicine National Center for Medical Education Development and Research

The 5th Annual Communities of Practice Conference

The Future of Medical Education and Clinical Services Transformation: Meeting the Needs of Vulnerable Populations in 2030

May 26-27, 2021 · A Virtual Conference

Department of Family and Community Medicine National Center for Medical Education Development and Research

The 5th Annual Communities of Practice Conference

The Future of Medical Education and Clinical Services Transformation: Meeting the Needs of Vulnerable Populations in 2030

May 26-27, 2021 · A Virtual Conference

What is a Community of Practice?

4th Annual Communities of Practice Conference

A community of practice (CoP) is a group of people who share a craft or a profession. The concept was first proposed by cognitive anthropologist Jean Lave and educational theorist Etienne Wenger in their 1991 book Situated Learning (Lave & Wenger 1991). Wenger then significantly expanded on the concept in his 1998 book Communities of Practice (Wenger 1998). A CoP can evolve naturally because of the members’ common interest in a particular domain or area, or it can be created deliberately with the goal of gaining knowledge related to a specific field. It is through the process of sharing information and experiences with the group that members learn from each other, and have an opportunity to develop personally and professionally (Lave & Wenger 1991).

(Lave & Wenger 1991).

The Primary Care Training and Enhancement Academic Units (AU) project is supported in part through a cooperative agreement (UH1HP30348) with the US Department of Health and Human Services (DHHS)/Health Resources and Services Administration (HRSA) and Department of Family and Community Medicine, School of Medicine, Meharry Medical College. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by DHHS, HRSA or the U.S. Government. 4

http://NCMEDR.org

Table of Contents

7 16 17 18 24 41 55 75 90 106 110 115 121 125 127 136 146

NCMEDR History and Years 1–5 Project Outcomes Read about the start of the Center and its project outcomes through CoP.

About NCMEDR

Get more information about the Center and its year 4 research areas.

Program-at-a-Glance

Get an overview of what happens and when.

Agenda

Take notes and engage in dynamic discussions with our content experts.

Year 1 Research Projects

View the Center’s research on Implicit Bias and Pre-Exposure Prophylaxis.

Year 2 Research Projects

Take a look at the Center’s research within Adverse Childhood Experiences and Interpersonal Violence.

Year 3 Research Projects

Check out our research projects on the topics of Opioid Misuse and Sexual Violence.

Year 4 Research Projects

Check out our research projects on the topics of Affirming Care and Immunizations..

Year 5 Research Projects

Check out our research projects on the topics of Mental Health and Telemedicine

Conference Posters

Review the sample of posters presented at national conferences.

2017 Readings on Vulnerable Populations

View the inaugural year’s topic references on Physician Bias and Pre-Exposure Prophylaxis.

2018 Readings on Vulnerable Populations

View last year’s topic references on Adverse Childhood Experiences and Interpersonal Violence.

2019 Readings on Vulnerable Populations View topic references on Interpersonal Violence and Opioids

2020 Readings on Vulnerable Populations View topic references on Affirming Care and Immunization Disparities

2021 Readings on Vulnerable Populations View topic references on Mental Health and Telehealth

NCMEDR Profile, Products, and Outcomes Funded Years 2016–2021

About the Speakers and Content Experts Learn more about this year’s speakers and content experts.

http://NCMEDR.org

NCMEDR History

5th Annual Communities of Practice Conference

The National Center for Medical Education Development and Research (NCMEDR) at Meharry Medical College was established to: » conduct systems-level research that transforms medical education and clinical practice which results in better health outcomes for LGBTQ populations, persons experiencing homelessness, and migrant farm workers; » grow a CoP that brings together academic faculty with community partners, advocates, and consumers to assist the Center develop recommendations for transforming medical education curriculum and clinical practice so as to better addresses the needs of vulnerable populations; and » translate medical education research into curriculum, policy, and practice recommendations and disseminate findings broadly to all interested audiences, including academic medicine and other health professions faculty, health professions providers, and community partners and advocates.

http://NCMEDR.org

5th Annual Communities of Practice Conference

NCMEDR History

The Center, through its CoP, is working to strengthen the capacity of medical schools to promote meaningful curriculum transformation. To achieve this overarching goal, we have conducted six (6) research studies presented below: Year One Topics and Outcomes: » Address implicit physician bias while working with vulnerable populations. » Systematic review completed of how medical schools are trained to address implicit physician bias towards vulnerable populations. Article submitted for publication. Paper is currently under review. » Survey of all US medical school undertaken to identify how they are addressing implicit physician bias among medical students towards LGBTQ persons, persons experiencing homelessness, and migrant farm workers. Paper is being prepared for submission. » Policy brief completed and disseminated on implicit physician bias. » Strategies to Reduce Physician Bias and Promote Culturally Competent Care for LGBTQ Patients: A Systematic Review of Interventions for Health Care Providers. Poster presentation at 10th Xavier Health Disparities Conference, 3/17/2017. » Physician Implicit Bias and LGBTQ Patients: A Systematic Review of Medical Student Education: Implications for Biomedical Education and Health Equity. Poster presentation at RCMI Science Translational Conference/DC, 10/26/2017. » Two videos completed of interviews with LGBTQ persons of their experience in receiving health care and posted on NCMEDR CoP YouTube Channel. » Cultural competency webinar completed with Dr. Matthews Juarez and posted on NCMEDR CoP YouTube Channel. » Identify how medical schools are preparing students to introduce Pre-Exposure Prophylaxis (PrEP) to vulnerable populations to prevent HIV transmission. » Completed systematic review of how medical schools are trained to address implicit physician bias towards vulnerable populations. Article submitted for publication. Paper is currently under review. » Survey of all US medical school conducted to identify how they are teaching medical students to address implicit physician bias towards LGBTQ persons, persons experiencing homelessness, and migrant farm workers. » Policy brief on PrEP completed and disseminated » Examining Differences in HIV Care Cascade Adherence and Health Outcomes be-tween African American MSM and MSW Poster presentation 10th Xavier Health Dis-parities Conference, 3/17/2017 » The Training of Medical Students in the Administration of Pre-Exposure Prophylaxis (PrEP) to Men and Transgender Women who have Sex with Men (MSM): A Systematic Review. Poster presentation at RCMI Science Translational Conference/DC, 10/26/2017.

http://NCMEDR.org

NCMEDR History

5th Annual Communities of Practice Conference

Year Two Topics and Outcomes: » Interpersonal violence across the lifespan among vulnerable populations. » Systematic review of literature completed (see program). Article is being prepared for submission for publication. » Juarez, PD. Screening for Violent Tendencies in Adolescents - A Focus On Causes, Effects And Screening. (Vince Morelli, Ed.). Adolescent Health Screening: an Update in the Age of Big Data. Elsevier. 2019. » Protocol for conducting survey of medical students at four HBCUs under review by MMC IRB. » Improving Patient Care Outcomes: Achieving Health Equity by Transforming Health Profession Training through an Interprofessional Patient- Centered Medical Home Model in Primary Care Settings. Beyond Flexner Conference, 4/9/2018. » Interpersonal Violence across the Life Course: Is there a need for a social mission in medical education transformation?” Beyond Flexner Conference, 4/9/2018. » Interpersonal Violence Across the Life Course. Poster presented at 11th Xavier Health Disparities Conference, 4/19/2018. » MEASURES FOR ENHANCING INTERPERSONAL VIOLENCE EDUCATION IN MEDICAL SCHOOLS. 11th Xavier Health Disparities Conference. 4/19/2018. » The effects of adverse childhood experiences (ACEs) in these three populations. » Systematic review of literature completed (see program). Article is being prepared for submission for publication. » Protocol for conducting survey of medical students at four HBCUs under review by MMC IRB. » Advancing Health Equity: Translating Research into Policy for Primary Care. AAMC/Orlando Florida. 4/24/2018. » The Art of Community of Practice as a Strategy: Transforming Medical Education and Clinical Practice to address Homelessness. National Health for the Homeless Council. 5/15/2018. » Transforming Medical Education and Clinical Practice to Address the Needs of Transgender Women: A Community of Practice Strategy. 11th Xavier Health Disparities Conference. 4/19/2018. » EDUCATIONAL INTERVENTIONS FOR ASSESSING ADVERSE CHILDHOOD EXPERIENCE. Poster presented at 11th Xavier Health Disparities Conference. 4/19/2018.

http://NCMEDR.org

5th Annual Communities of Practice Conference

NCMEDR History

Year Three Topics and Outcomes:: » Opioid Misuse among vulnerable populations. » Systematic review of the literature completed on how medical schools are teaching students to address opioid misuse. No articles were identified that addressed the needs of vulnerable populations. See program for a complete list of articles. Article is in preparation for journal submission. » Patient/provider survey of how opioid misuse is being addressed in primary care is under discussion. » Modeling disparities in opioid overdose deaths: Using data from a national health crisis to train medical students in health disparities. Presented at Beyond Flexner Conference, 4/9/2018. » Mobilizing Academic and Community Partnerships to Address the Needs of Vulnerable Populations: A Social Media Perspective for Working with LGBTQ, Homeless Persons, and Migrant Workers. Beyond Flexner Conference, 4/9/2018. » Testing Low Threshold Models for Medication Assisted Treatment In Primary Care Residencies. Beyond Flexner Conference, 4/9/2018. » Sexual Violence among vulnerable populations. » Systematic review of the literature completed on how medical schools are teaching students to address sexual violence among vulnerable populations. See program for a complete list of articles. Article is in preparation for journal submission. » Becoming Culturally Competent Healthcare Providers: A Prerequiste to Address Healthcare Disparities. Poster presented at 11th Xavier Health Disparities Conference. 4/19/2018. » Patient/provider survey of how opioid misuse is being addressed in primary care is under discussion.

http://NCMEDR.org

NCMEDR History

5th Annual Communities of Practice Conference

Year Four Topics and Outcomes: » Teaching Medical Students to Provide Gender Affirming Care for Transgender Patients: » Systematic review of the literature completed on how medical schools are teaching students to address gender affirming care. No articles were identified that addressed the needs of vulnerable populations. See program for a complete list of articles. Manuscript is in preparation for journal submission. » Curriculum module is under preparation. » In collaboration with our Communities of Practice members, a webinar was held on this topic on March 23, 2021. » Affirming and Inclusive Care Training for Medical Students and Residents. Poster presented at 14th Xavier Health Disparities Conference, 4/7/2021. » Transforming Primary Care Training: Collective Impact of a Community of Practice Model. Podium presentation at the 14th Xavier Health Disparities Conference, 4/7/2021. » Developing Communities of Practice for Collective Impact: A How-To Guide Featuring Case Studies from UC Davis Center for a Diverse Healthcare Workforce and Meharry Medical College National Center for Medical Education, Development, and Research. Tool kit presentation. Beyond Flexner Conference, 4/27/2021. » National Center for Medical Education, Development and Research. Podium presentation. Beyond Flexner Conference, 4/27/2021. » Addressing Immunization Disparities among Vulnerable Populations: » Systematic review of the literature completed on how medical schools are teaching students to address immunization disparities among vulnerable populations. See program for a complete list of articles. Manuscript is in preparation for journal submission. » Curriculum module is under preparation. See program for an outline. » In collaboration with our Communities of Practice members, a webinar was held on this topic on March 30, 2021. » Addressing Immunization Disparities through Educational Interventions. Poster presented at 14th Xavier Health Disparities Conference, 4/7/2021. » Transforming Primary Care Training: Collective Impact of a Community of Practice Model. Podium presentation at the 14th Xavier Health Disparities Conference, 4/7/2021. » Developing Communities of Practice for Collective Impact: A How-To Guide Featuring Case Studies from UC Davis Center for a Diverse Healthcare Workforce and Meharry Medical College National Center for Medical Education, Development, and Research. Tool kit presentation. Beyond Flexner Conference, 4/27/2021. » National Center for Medical Education, Development and Research. Podium presentation. Beyond Flexner Conference, 4/27/2021.

http://NCMEDR.org

5th Annual Communities of Practice Conference

NCMEDR History

Year Five Topics and Outcomes: » Preparing Medical Students to Use Telehealth to Address Disparities among Vulnerable Populations: » Systematic review of the literature completed on how medical schools are teaching students to use telehealth to address disparities among vulnerable populations. See program for a complete list of articles. Manuscript is in preparation for journal submission. » Curriculum module is under preparation. See program for an outline. » In collaboration with our Communities of Practice members, a webinar was held on this topic on April 6, 2021. » Assessment of Educational Interventions for Delivering Health Care through Telehealth. Poster presented at 14th Xavier Health Disparities Conference, 4/7/2021. » Transforming Primary Care Training: Collective Impact of a Community of Practice Model. Podium presentation at 14th Xavier Health Disparities Conference, 4/7/2021. » Developing Communities of Practice for Collective Impact: A How-To Guide Featuring Case Studies from UC Davis Center for a Diverse Healthcare Workforce and Meharry Medical College National Center for Medical Education, Development, and Research. Tool kit presentation. Beyond Flexner Conference, 4/27/2021. » National Center for Medical Education, Development and Research. Podium presentation. Beyond Flexner Conference, 4/27/2021. » Transforming Medical Education to Address Mental Health Disparities among Vulnerable Populations: » Systematic review of the literature completed on how medical schools are teaching students to address mental health disparities among vulnerable populations. See program for a complete list of articles. Manuscript is in preparation for journal submission. » Curriculum module is under preparation. See program for an outline. » In collaboration with our Communities of Practice members, a webinar was held on this topic on April 13, 2021. » Assessment of Educational Interventions for Addressing Mental Health. Poster presented at 14th Xavier Health Disparities Conference, 4/7/2021. » Transforming Primary Care Training: Collective Impact of a Community of Practice Model. Podium presentation at the 14th Xavier Health Disparities Conference, 4/7/2021. » Developing Communities of Practice for Collective Impact: A How-To Guide Featuring Case Studies from UC Davis Center for a Diverse Healthcare Workforce and Meharry Medical College National Center for Medical Education, Development, and Research. Tool kit presentation. Beyond Flexner Conference, 4/27/2021. » National Center for Medical Education, Development and Research. Podium presentation. Beyond Flexner Conference, 4/27/2021.

http://NCMEDR.org

The needs of many vulnerable populations are overlooked in medical education and training. The efforts of the NCMEDR to utilize conduct medical educatio incorporating evidence-based practices and futuristic thinking about clinical p The Department of National Center for Medical Education, Family & Community Medicine extraordinary. The Center has continued to work effectively and efficiently Development and Research leadership of Paul D. Juarez, PhD, the Center Director and the Vice Chair for C Engagement and Research. Along with the Project Director, Dr. Pat Matthews assembled an outstanding team of academicians, research scientists and transd members of a community of practice that reflected three vulnerable populations Welcome to the 5th Annual National Center for Medical Education Development and Research persons experiencing homelessness and migrant farm workers). (NCMEDR) Communities of Practice (CoP) Convening. It is with great pleasure that I bring you greetings on behalf of the Department of Family and Community Medicine at Meharry Medical College.

Thank you the faculty of the Center, Drs. Armandla Ramesh, Katheri The needs of many vulnerable populations are overlooked in medical education curriculum and Mohammad Tabatabai, and Robert Lyle Cooper. With incorporating their expertise i training. The efforts of the NCMEDR to use and conduct medical education research evidence-based practices and futuristic about clinical practice extraordinary. Center epidemiology, statistics, andthinking dissemination, they are added to the The excellence demo has continued to work effectively and efficiently under the leadership of Paul D. Juarez, PhD, the Center the Center. Their to the creation ways ofAlong thinking abo Director and the Vice Chaircommitment for Community Engagement and Researchoffornew the Department. with the Project Director, Dr. Pat and Matthews-Juarez, professor and Director of our Research education development researchwho is isoutstanding and reflects the mission Training Core in the Health Disparities Research Center of Excellence, Dr. Juarez has assembled an Medical College. outstanding team of academicians, research scientists and transdisciplinary members of a community

of practice. This team reflects knowledge, understanding, and experience about the three vulnerable populations (LGBTQ+, persons experiencing homelessness and migrant farm workers) who are often To you, members of the three communities of practice, we are externally grat limited in access to health services and faced with health inequities. Thank you to the faculty of the time given toKatherine the development and Tabatabai, successand ofRobert the NCMEDR. Your c Center,and Drs.efforts Aramandla Ramesh, Brown, Mohammad Lyle Cooper. With dedication their expertise in epidemiology, statistics, and are dissemination, addedidea to theof volunte and inresearch, working with the Center beyondthey thehave noble excellence demonstrated by the Center. Their commitment to the creation of new ways of thinking thank you education for your work inandthe development of reflects curriculum modules, about medical development research is outstanding and the mission of Meharry feedback Medical College. years, and your ability to innovatively expand the body of knowledge thr

contributions that included exceptional feedback. Your contribution assisted th To you, members of the three communities of practice, we are externally grateful for the time and efforts given to the success of the NCMEDR. Your commitment and dedication in establishing itsdevelopment nationaland agenda.

working with the Center are beyond the noble idea of volunteering. We thank you for your work in the development of curriculum modules, feedback across the years, and your ability to innovatively As chair, I look forward to seeing each ofthatyou, butexceptional even more importantly I lo expand the body of knowledge through your contributions included feedback. Your the Centerof in establishing its national tocontribution seeing assisted the impact over time of theagenda. work of the NCMEDR in transformi

care education and clinical services formore vulnerable As chair, I look forward to seeing each of you, but even importantly Ipopulations. look forward to seeing the

impact of over time of the work of the NCMEDR in transforming primary care education and clinical services for vulnerable populations.

Sincerely, Sincerely,

Millard Collins, M.D., FAAFP Millard D. D. Collins, M.D., FAAFP Chair && Associate ProfessorProfessor Chair Associate

National Center for Medical Education, Development and Research

Welcome Colleagues, CoP members, Content Experts, Thought Leaders, Meharry leadership, faculty, program faculty, and staff. In addition, I would like to recognize Dr. Irene Sandvold, our HRSA program officer. Dr. Sandvold serves as Director of the Medical Training and Geriatrics Branch, Division of Medicine and Dentistry, Bureau of Health Workforce, Health Resources and Services Administration and has been our North Star through this novel Administrative Units grant process, providing thoughtful insights, encouragement, and leadership. I would also like to give a sincere thank you to 1JoshuaGroup, who has been with us since the first CoP in supporting our conferences and bringing us together. These past twelve months have been a capstone year for the National Center for Medical Education, Training, and Research, culminating in this fifth year of convening of the Communities of Practice (CoP). and the production of many products that we look forward to sharing with you, across these next two days. We are eager to get your input and recommendations on how we can multiply the effects of our work through dissemination. Many of you have been with us from the start while others are new to the program, but not necessarily to us. We are excited to share with you the actual outcomes of our work. In addition, as a National Center, as we move forward, we are looking to sustain our work, even after the grant ends. We hope to continue to enlist your assistance in our research and in the translation and interpretation of our research findings into medical education curriculum to prepare medical students to be better trained in addressing the unique needs of LGBTQ persons, migrant farm workers, and persons experiencing homelessness as they move into clinical practice. Thank you for joining us. We look forward to a wonderful and productive two days. Sincerely,

Patricia Matthews-Juarez, PhD, HRSA AU Program Director Professor, Department of Family and Community Medicine Senior Vice President for Strategic Initiatives & Innovation, Office of the President Meharry Medical College

National Center for Medical Education, Development and Research Friends and Colleagues: Greetings and welcome to our second virtual, 2021 Communities of Practice (COP) Meeting, which also marks our fifth and final, Communities of Practice meeting. We are pleased to share with you the exciting progress that our CoP has made over the past year, as well as the full set of accomplishments that we have achieved over the past five years. In this year’s convening, you will hear about the outstanding progress that the CoP has made over the past twelve months, under the leadership of Drs. Katherine Y. Brown, Director of the CoP and Aramandla Ramesh, Senior Scientist and Research Director, together with Dr. Pat Matthews-Juarez and outstanding expertise and input from our CoP members. This past year, the year of COVID-19, we conducted research to assess the ways medical schools are teaching students to address the mental health needs of LGBTQ persons, migrant farm workers, and persons experiencing homelessness and how they are being taught to use telemedicine to provide coordinated care, improve patient outcomes, and quality. If there is a silver lining of the COVID-19 pandemic, it is that it has helped the nation better understand the degree of inequity that exists in the health care system, particularly for socially vulnerable populations. Our two topics: mental health and telemedicine both loomed large in the face of the COVID-19 pandemic. While the mental health needs of vulnerable populations affected by COVID-19 populations exposed many of the cracks in the primary and behavioral health care system, it also brought the use of telemedicine into practical use for many health care providers. Telemedicine portends exciting opportunities for being able to provide coordinated and quality health care services to socially vulnerable persons. The goals of this virtual, CoP convening are twofold: 1) to share the progress of the CoP over the past year, and 2) to get your input assisting in finalizing strategies and products for disseminating our findings to academic health center faculty as well as to medical education governing and regulatory bodies, such as the AMA Council on Medical Education, AAMC and the Liaison Committee on Medical Education (LCME). This year we have once again chosen to go on-line using the Zoom videoconferencing platform to convene this meeting. Even the use of virtualization, has been an exciting process. We look forward to the exchange this convening will bring. Thanks for your interest. Enjoy! Be ready to contribute! Stay safe! Sincerely,

Paul D. Juarez, PhD, Professor and Vice Chair for Research Department of Family and Community Medicine Director, National Center for Medical Education Development and Research Meharry Medical College

National Center for Medical Education, Development and Research May 26, 2021 Dear Thought Leaders, Experts, and Colleagues, It is with much excitement that we welcome you to the 5th Annual National Center for Medical Education Development and Research (NCMEDR) Communities of Practice (CoP) Convening. For the past five years, the Center has had the opportunity to work with you as we worked toward transforming medical education and clinical practice to meet the needs of vulnerable populations. As members of the CoP, you have provided extraordinary directions and feedback on how we can move forward for systematic change and sustainability. Over the last year, we have expanded our CoP engagement. This expansion has included weekly CoP meetings for feedback and review of our research on medical school curriculum for mental health, telemedicine, affirming care, and immunization disparities. Your work with us has given rise to even more in depth research discussions, production of policy briefs, and exceptional opportunities to conduct more precise systematic reviews. We have appreciated your participation in professional presentations, conferences, collaboration on publications, book chapters, and webinars. Your participation has amplified the contributions of the Center. We have been able to utilize social media tools to disseminate and communicate our work with you to a wide range of stakeholders and academicians. Our website to date has had over 1,383,308 total views (over the five year period) and our Twitter pages have had over 782,841 impressions. With the establishment of our Cable Television show, we reached 19 counties in Middle Tennessee, an estimated 161,000 households. We established five memorandums of understanding with national partners, produced four (4) clinical vignettes, and earned the Mayo Clinic Social Media Network Gold Fellowship. With your support, we have exceeded our goals and expectations. Even in the midst of a global pandemic (COVID19), our work has continued. We are thankful to you. During our time together for this year’s convening, we are excited about another opportunity to have you review the work of the Center and to explore ways that we can continue to serve vulnerable populations in innovative ways using evidence-based best practices. As we end five years of service to our stakeholders, we remain optimistic about the possibilities that exist to transform medical education and clinical practices in meaningful ways. Thank you for your continued commitment. I look forward to working with you. Sincerely,

Katherine Y. Brown

Katherine Y. Brown, EdD Assistant Professor, Department of Family and Community Medicine Director of Communities of Practice and Dissemination National Center for Medical Education Development and Research Meharry Medical College

About NCMEDR

5th Annual Communities of Practice Conference

In 2016, Health Resources and Services Administration (HRSA funded Meharry Medical College), through a cooperative agreement (#UH1HP30348), to establish the National Center for Medical Education Development and Research (NCMEDR), a new academic administrative unit whose purpose was to evaluate how medical schools in the United States are addressing the needs of vulnerable populations and to make recommendations that will have the impact of transforming medical education and clinical practice in Tennessee and across the country. For the purpose of this award, HRSA defined vulnerable populations as Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTq), persons experiencing homelessness, and migrant farm workers. The goals of NCMEDR are to: 1) conduct systems-level research of evidence-based, medical education curriculum that target the needs of vulnerable populations; 2) disseminate best practices and resources in medical education to academic medicine faculty and other interested parties across the mid-South; and 3) establish a Community of Practice (CoP) to enhance curriculum and practice transformation and dissemination that better addresses the health care needs of persons who are LGBTQ, experiencing homelessness or are migrant farm workers. The CoP was established to recruit diverse audiences, including academic medicine faculty, interprofessional health care professionals, and community partners, including persons with lived experiences, to: 1) review current medical education curriculum and clinical practice landscape, and 2) recommend changes to the training of medical students in order that better address the needs of vulnerable populations. The charge of the CoP is to assist the NCMEDR plan, conduct, translate, and disseminate research findings and policy recommendations that will transform medical education curriculum and practice in order to better meet the health care needs of vulnerable populations. It is anticipated that these findings and recommendations will be disseminated broadly to other medical schools to help them update their curriculum and teach students to better address the needs of vulnerable populations using a life course model and a systems framework. In addition, the CoP will assist the NCMEDR in conducting research on curriculum transformation, translating results into policy and practice recommendations, and disseminating findings to diverse interested audiences. It is anticipated that the CoP will give relevant and timely feedback on the review and/or development of primary care research, medical education curriculum toolkits and resources, including case studies for simulation, and strategies to translate and disseminate research findings that will prepare medical students to better deliver high quality, cost-effective, patient-centered care to vulnerable populations in under-served communities.

http://NCMEDR.org

4th Annual Communities of Practice Conference

Program at a Glance

DAY 1: WEDNESDAY, MAY 26, 2021 11:55 AM – 12:00 PM Virtual Waiting Room

Conference Waiting Room Opens

12:00 PM – 1:00 PM

Opening Webinar Session

The Importance of Diversity and Inclusion in Transforming Medical Education for Primary Care: Moving Towards Health Equity 1:00 PM – 1:15 PM

Transition to Breakout Sessions

1:15 PM – 1:45 PM

General Session I

Using a Community of Practice Model to Develop Medical Education Curriculum for Vulnerable Populations (LGBTQ, Persons Experiencing Homelessness, and Migrant Farmworkers) 1:50 PM – 2:40 PM

Concurrent Breakout Sessions A, B, C

Transforming Medical Education to Address Mental Disparities and COVID-19 Among Vulnerable Populations 2:45 PM – 3:00 PM

General I Closing

Closing General Session, Comments and Instructions

DAY 2: THURSDAY, MAY 27, 2021 11:55 AM – 12:00 PM Virtual Waiting Room

Conference Waiting Room Opens

12:00 PM – 1:00 PM

Town Hall Meeting

Developing a Culturally Competent Physician Workforce to Address the Needs of Vulnerable Populations (LGBTQ, Persons Experiencing Homelessness, and Migrant Farmworkers) 1:00 PM – 1:15 PM

Transition to Breakout Sessions

1:15 PM – 1:45 PM

General Session II

The Future of Telehealth in the U.S. – Meeting the Healthcare Needs of Vulnerable Populations 1:50 PM – 2:50 PM

Concurrent Breakout Sessions D, E, F

Preparing Medical Students to Use Telehealth to Address Health Disparities including COVID-19 Among Vulnerable Populations 2:50 PM – 3:10 PM

Closing Session

Communities of Practice Lessons Learned & Pathways Forward http://NCMEDR.org

Program Agenda

5th Annual Communities of Practice Conference

OPENING WEBINAR SESSION

The Importance of Diversity and Inclusion in Transforming Medical Education for Primary Care: Moving Towards Health Equity Wednesday, May 26, 2021 • 12:00 PM – 1:00 PM Welcome & Overview

Patricia Matthews-Juarez, PhD Meharry Medical College

Greetings

James E.K. Hildreth, PhD, MD Meharry Medical College

Greetings

Digna S. Forbes, MD Meharry Medical College

Greetings

Millard D. Collins, MD Meharry Medical College

Greetings

Irene O. Sandvold, DrPH, MSN HRSA

Greetings

Katherine Y. Brown, EdD Meharry Medical College

Greetings & Introductions The Importance of Diversity and Inclusion in Transforming Medical Education for Primary Care: Moving Towards Health Equity Moderated Q & A and Closing

Paul D. Juarez, PhD Meharry Medical College David A. Acosta, MD Chief Diversity Officer American Association of Medical Colleges (AAMC)

Paul D. Juarez, PhD Meharry Medical College

GENERAL SESSION I

Using a Community of Practice of Practice Model to Develop Medical Education Curriculum for Vulnerable Populations (LGBTQ, Persons Experiencing Homelessness, and Migrant Farm Workers) Wednesday, May 26, 2021 • 1:15 PM – 1:45 PM Moderator Presentation of Year 4 Module – Affirming Care

Asa Radix, MD, PhD, MPH Callen-Lorde Community Health Center

Presentation of Year 5 Module – Mental Health

Jayne S. Reuben, PhD Texas A&M University College of Dentistry

The Importance of Using a Community of Practice Model in Medical Education

Freida H. Outlaw, PhD American Nurses Association

Breakout Sessions Instructions 18

Katherine Y. Brown, EdD Meharry Medical College

http://NCMEDR.org

Katherine Y. Brown, EdD Meharry Medical College

Program Agenda

5th Annual Communities of Practice Conference CONCURRENT BREAKOUT SESSION A

Transforming Medical Education to Address Mental Health Disparities and COVID-19 Among Vulnerable Populations – Interventions for LGBTQ Persons Wednesday, May 26, 2021 • 1:50 PM – 2:50 PM Moderator / Facilitator Thought Leader & Content Expert Stakeholder Experience Stakeholder Experience & Reporter

Leandro A. Mena, MD, MPH University of Mississippi Medical Center Sanell McGoy, PhD, MPH Eboni Winford, PhD, MPH Cherokee Health Knoxville Tennessee Donald J. Alcendor, PhD Meharry Medical College

CONCURRENT BREAKOUT SESSION B

Transforming Medical Education to Address Mental Health Disparities and COVID-19 Among Vulnerable Populations – Interventions for Persons Experiencing Homelessness Wednesday, May 26, 2021 • 1:50 PM – 2:50 PM Moderator / Facilitator Thought Leader & Content Expert Stakeholder Experience Reporter

Suzanne L. Wenzel, PhD University of Southern California Marybeth Shinn, PhD Vanderbilt University Stephanie White, MD, MS University of Kentucky Keaton S. Thorum, BS, BA Virginia Commonwealth University

CONCURRENT BREAKOUT SESSION C

Transforming Medical Education to Address Mental Health Disparities and COVID-19 Among Vulnerable Populations – Interventions for Migrant Farm Workers Wednesday, May 26, 2021 • 1:50 PM – 2:50 PM Moderator / Facilitator Thought Leader & Content Expert Stakeholder Experience Reporter

Deliana Garcia, MA Migrant Clinicians Network Thomas A. Arcury, PhD Wake Forest School of Medicine James Cruz, MD Blue Shield of Southern California Promise Health Plan Margareth Larose, PharmD Florida A&M University

http://NCMEDR.org

Program Agenda

5th Annual Communities of Practice Conference

GENERAL SESSION I CLOSING

Reporting & Closing Remarks Wednesday, May 26, 2021 • 2:50 PM – 3:05 PM Moderator

Katherine Y. Brown, EdD Meharry Medical College

Breakout A: Interventions for LGBTQ

Donald J. Alcendor, PhD Meharry Medical College

Breakout B: Interventions for Persons Experiencing Homelessness

Keaton S. Thorum, BS, BA Virginia Commonwealth University

Breakout C: Interventions for Migrant Farm Workers Closing Remarks

Margareth Larose, PharmD Florida A&M University

Katherine Y. Brown, EdD Meharry Medical College

TOWN HALL MEETING

Developing a Culturally Competent Physician Workforce to Address the Needs of Vulnerable Populations (LGBTQ, Persons Experiencing Homelessness, and Migrant Farm Workers) Thursday, May 27, 2021 • 12:00 PM – 1:00 PM Welcome & Introductions Addressing Mental Health Services for Vulnerable Populations in Primary Care Training and Clinical Services: Tools for Intersectionality

Altha J. Stewart, MD University of Tennessee Health Science Center

Training Healthcare Professionals While Caring for Persons Experiencing Homelessness: An Act of Social Justice

G. Robert (Bobby) Watts, MPH, MS, CPH National Health Care for the Homeless Council

The Culturally Competent Primary Care Physician’s Role in Caring for Vulnerable Populations Moderated Discussion, Q&A, and Closing

Patricia Matthews-Juarez, PhD Meharry Medical College

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Sonja Harris-Haywood, MD Northeast Ohio Medical University

Patricia Matthews-Juarez, PhD Meharry Medical College

Program Agenda

5th Annual Communities of Practice Conference GENERAL SESSION II

The Future of Telehealth in the U.S. Meeting the Healthcare Needs of Vulnerable Populations Thursday, May 27, 2021 • 1:15 PM – 1:45 PM Moderator / Facilitator Telehealth and Access Disparities in South Carolina The Future of Telehealth: Meeting the Needs of Vulnerable Populations Q&A / Introductions for Breakout Sessions

Renee S. Frazier, MHSA Meharry Medical College James T. McElligott, MD Medical University of South Carolina

Febe I. Wallace, MD Cherokee Health Systems

Renee S. Frazier, MHSA Meharry Medical College

CONCURRENT BREAKOUT SESSION D

Preparing Medical Students to Use Telehealth to Address Health Disparities including COVID-19 Among Vulnerable Populations — Interventions for Lesbian, Gay, Bisexual, Transgender, Queer / Questioning Persons Thursday, May 27, 2021 • 1:50 PM – 2:50 PM Moderator / Facilitator Thought Leader & Content Expert Stakeholder Experience Reporter

Cheryl L. Holder, MD Florida International University Leandro A. Mena, MD, MPH University of Mississippi Medical Center Robert Lyle Cooper, III, PhD Meharry Medical College Aramandla Ramesh, PhD Meharry Medical College

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Program Agenda

5th Annual Communities of Practice Conference

CONCURRENT BREAKOUT SESSION E

Preparing Medical Students to Use Telehealth to Address Health Disparities including COVID-19 Among Vulnerable Populations — Interventions for Persons Experiencing Homelessness Thursday, May 27, 2021 • 1:50 PM – 2:50 PM Moderator / Facilitator Thought Leader & Content Expert

Stakeholder Experience Reporter

Regina S. Offodile, MS, MMHC, MHPE, MSPH Meharry Medical College G. Robert (Bobby) Watts, MPH, MS, CPH National Health Care for the Homeless Council Lawrence Byrant, PhD, MPH Kennesaw State University Allyson S. Belton, MPH Morehouse School of Medicine

CONCURRENT BREAKOUT SESSION F

Preparing Medical Students to Use Telehealth to Address Health Disparities including COVID-19 Among Vulnerable Populations — Interventions for Migrant Farm Workers Thursday, May 27, 2021 • 1:50 PM – 2:50 PM Moderator / Facilitator Thought Leader & Content Expert Stakeholder Experience Reporter

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Jayne S. Reuben, PhD Texas A&M University College of Dentistry Marvin L. Crawford, MD, MDiv Morehouse School of Medicine Deliana Garcia, MA Migrant Clinicians Network Janeth Ceballos Osorio, MD University of Kentucky

Program Agenda

5th Annual Communities of Practice Conference REPORTING & CLOSING SESSION

Communities of Practice Lessons Learned & Pathways Forward Thursday, May 27, 2021 • 2:50 PM – 3:10 PM Moderator

Katherine Y. Brown, EdD Meharry Medical College

Breakout D: Interventions for LGBTQ

Aramandla Ramesh, PhD Meharry Medical College

Breakout E: Interventions for Persons Experiencing Homelessness

Allyson S. Belton, MPH Morehouse School of Medicine

Breakout F: Interventions for Migrant Farm Workers

Janeth Ceballos Osorio, MD University of Kentucky

Closing Remarks

Patricia Matthews-Juarez, PhD Meharry Medical College

Closing Remarks

Katherine Y. Brown, EdD Meharry Medical College

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Year 1 Research Projects

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YEAR 1 SYSTEMATIC REVIEW

Medical Education Efforts to Reduce Implicit Bias towards LGBTQ Patients EXECUTIVE SUMMARY BACKGROUND Over the last three decades, there has been a growing recognition that biased attitudes and beliefs of health care providers towards LGBTQ patients in the healthcare system contribute to disparities through its impact on healthcare access and quality of clinical care1,2

METHODS We conducted a systematic review of the literature using the 2009 PRISMA guidelines3 to identify original studies that focused on how medical schools are training students to address implicit bias towards LGBTQ persons. An electronic search was conducted in MEDLINE/PubMed, PsycINFO, Web of Science, Scopus, Ingenta, Science Direct, and Google Scholar databases for articles in English published prior to February 2017.

RESULTS Effective programs designed to increase student or provider knowledge of the LGBTQ community and LGBTQ-relevant health care issues utilized lectures, readings, videos, interviews and presentations by LGBTQ individuals, and group discussion. Significant knowledge gains were observed for students attending single-session4-6 and for students and providers attending more timeintensive program formats7,8. The only study assessing knowledge retention found that knowledge gains for medical students were maintained three months after the training program9. Other programs designed to reduce LGBTQ-related bias in non-providers showed that: 1) educational components can be effective at increasing knowledge about the LGBTQ community; 2) contact with LGBTQ individuals is effective at promoting positive attitudes; 3) the combination of education and intergroup contact is effective at changing attitudes and behavioral intentions; and 4) providing information regarding social norms is effective at changing behavior10.

RECOMMENDATIONS A curricular framework for reducing implicit biases towards LGBTQ persons and other vulnerable populations among medical students is needed and has the potential of transforming medical school education. Bias awareness strategies are more effective when practiced in a supportive and individualized learning environment such as a patient simulation that provides students with opportunities to receive direct feedback out perceived implicit biases while minimizing student defensiveness11.

KEY STAKEHOLDERS Key stakeholders include but are not limited to academic medical institutions, medical education accreditation bodies, health care providers, advocacy groups, public health officials, policymakers, health professions associations, and populations at risk.

METHODS We conducted a systematic review of the literature using the 2009 PRISMA guidelines39 to identify original studies that focused on reducing medical student or health care provider bias towards LGBTQ persons. An electronic search was conducted in MEDLINE/ PubMed, PsycINFO, Web of Science, Scopus, Ingenta, Science Direct, and Google Scholar databases for articles in English published prior to February 2017. The search strategy cross-referenced keywords for LGBTQ populations (lesbian, gay, bisexual, transgender, questioning, homosexual, MSM, WSW, sexual minority) with keywords for health care professions students or providers (medical student, medical resident, provider, physician, doctor, nurse, health personnel, practitioner, fellow, social worker) and keywords for bias (implicit bias, explicit bias, de-biasing, cultural competence, cultural competency, discrimination, prejudice, health disparity). To be included in this systematic review, a study had to: 1) assess LGBTQ-related bias; 2) include dental, nursing or medical students or practicing medical professionals; 3) include a training program designed to promote culturally-competent care for LGBTQ individuals; 4) be written in English; and 5) be published prior to February 2017. We did not exclude qualitative studies nor did we exclude studies conducted outside of North America.

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LIMITATIONS Findings of the systematic review were limited as none addressed the impact of implicit bias training on changing students’ behavior or on patient outcomes. Hence, we could only draw from the extant literature on implicit racial/ethnic bias reduction to generate recommendations for training to address implicit bias towards LGBTQ persons and other vulnerable populations3, 39, 40.

RESULTS/KEY FINDINGS The systematic literature search yielded nine studies that assessed training programs to reduce LGBTQ-related bias in health care professions students and four studies that focused on health care providers. Studies ranged from small sample size (n = 13) to large (n = 848) and represented a wide range of health professions training programs including medicine (n = 6), nursing (n = 2) and dentistry (n = 1), as well as health care providers (n = 4). The programs varied in their delivery format (e.g., lecture, small group discussion, interactive theater workshop), frequency (range: 1 to 6 sessions) and duration (range: 45-minute lecture to 4-week web-based course). Programs designed to increase student or provider knowledge of the LGBTQ community and LGBTQ-relevant health care issues utilized lectures, readings, videos, interviews or presentations by LGBTQ individuals, and group discussion. Significant knowledge gains in knowledge were observed for students attending single-session41-44 and for students and providers attending more time-intensive program formats45, 46. One found that knowledge gains for medical students were maintained three months after the training program46. Programs designed to promote more positive student attitudes toward LGBTQ patients utilized perspective-taking exercises, videos of LGBTQ patients describing discrimination in health care settings, individual presentations, lectures, and LGBTQ patient panels. Strategies that reduce biases in students and providers are likely to increase access to care and reduce health disparities among vulnerable populations.

DISCUSSION The present review provides direction for researchers and educators seeking to reduce implicit bias among medical students toward LGBTQ patients and other vulnerable populations and provides a blueprint that can be used to train students how to become aware of and address personal biases. While research on programs to reduce bias among medical students is limited, research with health professionals may shed light on the key ingredients of effective programs. This review found that comfort level regarding LGBTQ health care was increased through experiential learning, which is consistent with prior results found in health professions samples47. Once implicit biases have been identified, medical students can be taught strategies to reduce their potential impact on patient care39. Some of these strategies, such as perspective-taking and intergroup contact, were identified in the present review as effective components of programs seeking to promote more positive explicit attitudes and greater comfort working with LGBTQ patients. Strategies that have received support for reducing implicit bias in other populations include: 1) the use of mindfulness meditation to promote nonjudgmental awareness48,49 2) individuation training to encourage providers to focus on individual attributes rather than group membership50; and 3) training in emotion regulation skills to reduce stress levels and negative emotions1,51. Although changes in implicit bias were not assessed using quantitative measures, anecdotal evidence from two studies found that an increase in awareness of implicit bias can be achieved among students41, 52. Future studies and medical school training programs should examine the influence of training on implicit LGBTQ-related bias.

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RECOMMENDATIONS/NEXT STEPS A curricular framework for reducing implicit biases among medical students towards LGBTQ persons and other vulnerable populations is needed and offers the potential for transforming medical school education in addressing the needs of vulnerable populations. Training activities and modalities that reduce bias towards LGBTQ persons and other vulnerable populations through increases in knowledge, explicit attitudes, and comfort level are supported by the present review. Results suggest that bias awareness strategies should be practiced in a supportive and individualized learning environment such as patient simulation that provides students with opportunities to receive direct feedback about perceived implicit biases while minimizing student defensiveness39. Towards this end, curricula should emphasize that implicit biases – whether negative or positive – are universal psychological phenomena51. While the Association of American Medical Colleges Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development has generated professional competency objectives, they currently are only advisory. Further review of incorporating professional competency objectives of the needs of LGBTQ and other vulnerable populations into accreditation standards of the Liaison Committee on Medical Education (LCME) should be considered.

ACKNOWLEDGMENTS This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UH1HP30348, entitled “Academic Units for Primary Care Training and Enhancement.” This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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10. Bartos SE, Berger I, Hegarty P. Interventions to reduce sexual prejudice: a study-space analysis and meta-analytic review. J Sex Res. 2014;51(4):363-382. 11. Zestcott, C. A., Blair, I. V. & Stone, J. Examining the presence, consequences, and reduction of implicit bias in health care: A narrative review. Group Process Intergroup Relat. 2016. doi:10.1177/1368430216642029. 12. Williams EC, Bradley KA, Balderson BH, et al. Alcohol and associated characteristics among older persons living with human immunodeficiency virus on antiretroviral therapy. Subst Abus. 2014;35(3):245-253. 13. Remafedi G, French S, Story M, Resnick MD, Blum R. The relationship between suicide risk and sexual orientation: results of a population-based study. Am J Public Health. 1998;88(1):57-60. 14. Quinn GP, Sanchez JA, Sutton SK, et al. Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/ questioning (LGBTQ) populations. CA Cancer J Clin. 2015;65(5):384-400. 15. Conron KJ, Mimiaga MJ, Landers SJ. A Population-Based Study of Sexual Orientation Identity and Gender Differences in Adult Health. American Journal of Public Health. 2010;100(10):1953-1960. 16. Dilley JA, Simmons KW, Boysun MJ, Pizacani BA, Stark MJ. Demonstrating the Importance and Feasibility of Including Sexual Orientation in Public Health Surveys: Health Disparities in the Pacific Northwest. American Journal of Public Health. 2010;100(3):460-467. 17. Fredriksen-Goldsen KI, Kim H-J, Barkan SE, Muraco A, HoyEllis CP. Health Disparities Among Lesbian, Gay, and Bisexual Older Adults: Results From a Population-Based Study. American Journal of Public Health. 2013;103(10):1802-1809. 18. Bauermeister J, Eaton L, Stephenson R. A Multilevel Analysis

5th Annual Communities of Practice Conference of Neighborhood Socioeconomic Disadvantage and Transactional Sex with Casual Partners Among Young Men Who Have Sex with Men Living in Metro Detroit. Behav Med. 2016;42(3):197-204. 19. Smalley KB, Warren JC, Barefoot KN. Differences in Health Risk Behaviors Across Understudied LGBT Subgroups. Health Psychology. 2016;35(2):103-114. 20. Cochran SD, Bandiera FC, Mays VM. Sexual orientationrelated differences in tobacco use and secondhand smoke exposure among US adults aged 20 to 59 years: 2003-2010 National Health and Nutrition Examination Surveys. Am J Public Health. 2013;103(10):1837-1844. 21. Charlton BM, Corliss HL, Missmer SA, et al. Reproductive health screening disparities and sexual orientation in a cohort study of U.S. adolescent and young adult females. J Adolesc Health. 2011;49(5):505-510. 22. Haas AP, Eliason M, Mays VM, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: review and recommendations. J Homosex. 2011;58(1):10-51. 23. Buchmueller T, Carpenter CS. Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000-2007. Am J Public Health. 2010;100(3):489-495. 24. Heck JE, Sell RL, Gorin SS. Health care access among individuals involved in same-sex relationships. Am J Public Health. 2006;96(6):1111-1118. 25. Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Social Science & Medicine. 26. Grant JM, Mottet LA, Tanis J. National Transgender Discrimination Survey Report on Health and Health Care. Washington DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2010. 27. Burke SE, Dovidio JF, Przedworski JM, et al. Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People Among Heterosexual Medical Students? A Report from Medical Student CHANGES. Academic medicine : journal of the Association of American Medical Colleges. 2015;90(5):645-651. 28. Sabin JA, Riskind RG, Nosek BA. Health Care Providers’ Implicit and Explicit Attitudes Toward Lesbian Women and Gay Men. Am J Public Health. 2015;105(9):1831-1841. 29. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics. 2017;18:19. 30. Rowniak SR. Factors Related to Homophobia Among Nursing Students. J Homosex. 2015;62(9):1228-1240. 31. Blair IV, Havranek EP, Price DW, et al. Assessment of Biases Against Latinos and African Americans Among Primary Care Providers and Community Members. American Journal of Public Health. 2012;103(1):92-98. 32. Sullivan PS, Rosenberg ES, Sanchez TH, et al. Explaining

Year 1 Research Projects racial disparities in HIV incidence in black and white men who have sex with men in Atlanta, GA: a prospective observational cohort study. Annals of epidemiology. 2015;25(6):445-454. 33. Millett GA, Peterson JL, Flores SA, et al. Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a metaanalysis. Lancet. 2012;380(9839):341-348. 34. Mereish EH, Bradford JB. Intersecting Identities and Substance Use Problems: Sexual Orientation, Gender, Race, and Lifetime Substance Use Problems. Journal of Studies on Alcohol and Drugs. 2014;75(1):179-188. 35. Torres CG, Renfrew M, Kenst K, Tan-McGrory A, Betancourt JR, Lopez L. Improving transgender health by building safe clinical environments that promote existing resilience: Results from a qualitative analysis of providers. Bmc Pediatrics. 2015;15. 36. Kamen C, Palesh O, Gerry AA, et al. Disparities in Health Risk Behavior and Psychological Distress Among Gay Versus Heterosexual Male Cancer Survivors. Lgbt Health. 2014;1(2):86-U103. 37. Khan A, Plummer D, Hussain R, Minichiello V. Does physician bias affect the quality of care they deliver? Evidence in the care of sexually transmitted infections. Sexually Transmitted Infections. 2008;84(2):150-151. 38. AAMC Advisory Committee on Sexual Orientation GI, and Sex Development,. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born with DSD: A Resource for Medical Educators. 2014. 39. Zestcott CA, Blair IV, Stone J. Examining the Presence, Consequences, and Reduction of Implicit Bias in Health Care: A Narrative Review. Group processes & intergroup relations : GPIR. 2016;19(4):528-42. doi:10.1177/1368430216642029 40. Valverde EE, DiNenno EA, Schulden JD, Oster A, Painter T. Sexually transmitted infection diagnoses among Hispanic immigrant and migrant men who have sex with men in the United States. International Journal of Std & Aids. 2016;27(13):1162-9. doi:10.1177/0956462415610679 41. Carabez R, Pellegrini M, Mankovitz A, Eliason MJ, Dariotis WM. Nursing students’ perceptions of their knowledge of lesbian, gay, bisexual, and transgender issues: effectiveness of a multi-purpose assignment in a public health nursing class. The Journal of nursing education. 2015;54(1):50-3. doi:10.3928/01484834-20141228-03 42. Eriksson SE, Safer JD. Evidence-Based Curricular Content Improves Student Knowledge and Changes Attitudes Towards Transgender Medicine. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2016;22(7):837-41. doi:10.4158/EP151141.OR 43. Strong KL, Folse VN. Assessing undergraduate nursing students’ knowledge, attitudes, and cultural competence

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Year 1 Research Projects in caring for lesbian, gay, bisexual, and transgender patients. The Journal of nursing education. 2015;54(1):45-9. doi:10.3928/01484834-20141224-07 44. Thomas D.D., Safer J.D. A Simple Intervention Raised Resident-Physician Willingness to Assist Transgender Patients Seeking Hormone Therapy. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2015;21(10):1134-42. doi:10.4158/EP15777.OR 45. Hardacker CT, Rubinstein B, Hotton A, Houlberg M. Adding silver to the rainbow: the development of the nurses’ health education about LGBT elders (HEALE) cultural competency curriculum. Journal of nursing management. 2014;22(2):25766. doi:10.1111/jonm.12125 46. Johnson K, Rullo J, Faubion S. Student-Initiated Sexual Health Selective as a Curricular Tool. Sexual medicine. 2015;3(2):118-27. doi:10.1002/sm2.57 47. Turner RN, Crisp RJ, Lambert E. Imagining intergroup contact can improve intergroup attitudes. Group Process Intergroup Relat. 2007;10(4):427-41. doi:10.1177/1368430207081533 48. Lueke A, Gibson B. Mindfulness Meditation Reduces Implicit Age and Race Bias: The Role of Reduced Automaticity of

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5th Annual Communities of Practice Conference Responding. Soc. Psychol. Personal Sci. 2015;6(3):284-91. doi:10.1177/1948550614559651 49. Stell AJ, Farsides T. Brief loving-kindness meditation reduces racial bias, mediated by positive other-regarding emotions. Motiv. Emot. 2016;40(1):140-7. doi:10.1007/s11031-015-9514-x 50. Stone J, Moskowitz GB. Non-conscious bias in medical decision making: what can be done to reduce it? Medical education. 2011;45(8):768-76. doi:10.1111/j.13652923.2011.04026.x 51. Kirwan Institute. State of the Science: Implicit Bias Review 2016. 2016. 52. Kelley L, Chou CL, Dibble SL, Robertson PA. A critical intervention in lesbian, gay, bisexual, and transgender health: knowledge and attitude outcomes among secondyear medical students. Teaching and learning in medicine. 2008;20(3):248-53. doi:10.1080/10401330802199567

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YEAR 1 SYSTEMATIC REVIEW

Training of Medical Students and Residents in the Administration of Pre-Exposure Prophylaxis EXECUTIVE SUMMARY BACKGROUND Although the incidence of Human Immunodeficiency Virus (HIV) has been declining over the past decade, approximately 50,000 new infections are diagnosed annually in the United States. Men who have sex with men (MSM) and transgender women continue to have higher rates of infection in the US. MSM make up 58% of people living with HIV, although they only account for 2% of the population. People who inject drugs (PWID) account for an additional 8% of newly diagnosed HIV infections while African American women account for 19%. A growing body of research has shown high levels of Pre-exposure prophylaxis (PrEP) efficacy in reducing the risk of contracting HIV. PrEP has been found to reduce the risk of infection between 44% and 86%, and with greater adherence, reductions are even higher. Despite the high efficacy of PrEP, prescription rates remain low. The study was guided by two questions: 1) Are medical students currently being taught how to prescribe PrEP for patients who are at risk for HIV? 2) What are the barriers to prescribing PrEP?

METHODS A systematic review of the literature was conducted using three databases (PubMed, CINAHL, & Web of Science) to address the research questions. Search terms included: HIV prevention, pre-exposure prophylaxis, primary care, medical education and training. A total of 560 articles were found. Titles and abstracts were reviewed to determine relevance to the research questions and eliminate duplicate articles reducing this number to 26. The full text of the 26 articles were then reviewed for relevance to the research questions. Twenty-one (21) articles remained for inclusion in this review.

RESULTS No articles or studies were found that focused on how prescribing PrEP is being taught to medical students. Barriers to prescribing PrEP by practicing primary care providers were identified, however, and a PrEP cascade for prescribing PrEP was identified.

RECOMMENDATIONS This review included four recommendations: 1) Medical schools should adapt a universal PrEP curriculum for its patient population using the PrEP cascade model; 2) medical students should be taught how to universally screen candidates for PrEP appropriateness (MSM, transgender women, discordant couples, African American women, young persons who have multiple partners, and PWID); 3) Medical students need to be familiar with patient medication assistance programs; and 4) medical students need to be taught how to monitor PrEP adherence.

KEY STAKEHOLDERS Key stakeholders include but are not limited to academic medical institutions, medical education accreditation bodies, health care providers, advocacy groups, health insurance providers, pharmaceutical companies, public health officials, policymakers, health professions associations, and populations at risk.

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BACKGROUND The efficacy of PrEP as a preventative measure, has been tested in multiple studies,14-20 and meta-analyses21,22 and findings suggest that, when used consistently, PrEP results in significantly decreased rates of HIV infection. A recent meta-analysis of PrEP efficacy confirmed that PrEP was equally effective for men and women.23 Despite the high level of efficacy of PrEP, less than 4.2% of persons in the US who would benefit from it, currently have a PrEP prescription. In order for PrEP to reach its full potential in reducing HIV, those individuals at highest risk must gain widespread access. This access will only be achieved by increasing the pool of willing and able prescribing physicians and consumers. While barriers to PrEP prescribing to at-risk populations have been noted in the literature,33-53 training medical students to prescribe will be critical to the full realization of PrEP’s preventive possibilities. While PrEP is an important tool for ending the HIV epidemic. Yet, there is no evidence that US medical schools currently are training students how to administer PrEP. Knowledge among primary care providers about PrEP is low and medical students are not being taught to prescribe it. To reduce the incidence of HIV infection, accrediting bodies should take a position on making the integration of PrEP prescription training mandatory in all all US medical schools. The goals of this review were to determine prescribing practices of primary care physicians, how prescribing was taught in medical schools and to make recommendations for enhancements in medical education to ensure that physicians entering practice will have the knowledge, skills, and intent to deliver PrEP to at-risk populations with the long term aim of ending the HIV epidemic. The need to develop curricula that include PrEP training is directly in line with the National HIV/AIDS prevention strategy to better equip doctors with the skills needed to reduce the incidence of HIV. We organized our findings utilizing the PrEP cascade,34 (see Table 1.) and provide both content and educational delivery method recommendations.

METHODS To address the research questions, a systematic review of articles was conducted from four databases (PubMed, CINAHL, Web of Science and PsycInfo). Search terms, inclusion and exclusion criteria were developed to conduct the systematic review. Initially, a total of 560 articles were found that met the search criteria. Next, titles and abstracts were reviewed to determine relevance to the research questions and to eliminate duplicate articles which reduced this number to 26. The full text of the 26 articles were then reviewed for relevance to the research questions. The CORE-Q checklist 54 was used to review qualitative studies and the STROBE checklist 55 for cross sectional surveys. After the full text review, 21 articles remained for inclusion in the review.

LIMITATIONS The limitations of our study included the small sample size of articles that fit the search criteria, and the gaps in current literature regarding physicians’ knowledge, skills, and prescription behavior regarding PrEP. The most evident gap is the lack of studies that have examined the effectiveness of PrEP prescription training to medical students on increasing PrEP prescription behavior. In addition, few studies have examined the rate of at-risk patients who may benefit from PrEP prescription in primary care.

RESULTS The systematic review found no articles or studies that focused on how PrEP prescription is being taught to medical students. Results found, however, that among health care providers, there has been much confusion about whether PrEP should be delivered by HIV specialists or by primary care providers.34 The purview barrier refers to HIV specialists being the most informed and skilled in the delivery of antiretrovirals, contrasted with the need for primary care physicians to deliver PrEP as they are more likely to encounter high risk, HIV negative persons. Generalists often cited the lack of knowledge about antiretroviral medications as a barrier to implementing PrEP in general practice settings.40,43,50 A national study of PrEP providers conducted annually from 2009-201544 found that HIV specialists were most likely to prescribe PrEP, but over time, the number of primary care physicians prescribing PrEP has steadily risen.42,43 Other systemic provider concerns identified, included a lack of resources to support prescriptions for PrEP patients,34,45,52 and the need for adherence monitoring.33,37,40,47-52 PrEP prescription without financial assistance is expensive, and many patients that may benefit most from PrEP may not have insurance or a means to pay for the prescription. Physicians in several of the studies noted this concern.34,45,52 However, a wealth of resources were identified to support patients that are appropriate candidates for the medication, including the Patient Advocacy Foundation, Gillead Sciences, and many state based programs.33 Additionally, for PrEP to be successful, adherence must be monitored and encouraged and regular check-ups are included in the PrEP protocol to identify any adverse consequences from the medication. 33,37,40,47-52 To achieve this, providers will need to increase patient communication regarding sexual risk, increase knowledge and willingness to prescribe PrEP, identify patient sexual risk behavior, and discuss these risks nonjudgmentally. Each of these factors can decrease the likelihood of providers prescribing PrEP.

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DISCUSSION For PrEP to be delivered on a scale that can reduce HIV transmission among at-risk populations and fulfill its potential role for ending the epidemic, consensus among medical educators on the venue for PrEP must be agreed upon and communicated. Delivering PrEP in primary care settings will require sexual histories to be taken regularly, HIV testing to be performed more frequently, and HIV prevention messages to be delivered in culturally appropriate ways and made universally to a wide range of patients. Medical students must be exposed to training in LGBTQ and PWID affirming practices. In order for PrEP to be delivered in real world settings, primary care physicians will need training to identify appropriate candidates for PrEP based on risk assessment, patient data from electronic medical records, patient preferences for use of chemoprophylaxis, and to become comfortable in prescribing and monitoring patient adherence and knowledge about patient assistance programs. Primary care residency training programs might focus on low cost methods (i.e., self-report for monitoring adherence in the patient-centered medical home clinical setting to ensure cost of PrEP remains low and available to promote patient adherence. Because mental health and substance abuse are factors that impact adherence and retention, medical students should receive training in screening and intervention approaches to ensure these barriers do not affect medication adherence. These skills have broad applicability and can easily be integrated into the medical school education curriculum. If PrEP is to be a viable preventive measure and to realize its potential in ending the HIV epidemic, physicians must be trained to deliver PrEP and barriers to prescribing it must be addressed in training. Integrating PrEP prescription training into the curriculum will aid in the fight to end the HIV epidemic. The PrEP cascade was identified as a framework for teaching medical students and residents the requisite knowledge and skills to deliver PrEP in their future practice and for assessing PrEP delivery and adherence. The PrEP Cascade, adapted from Liu, Colfax, Bacon, Kolber, et al. (2015) is presented in Table 1.

TABLE 2: ELEMENTS OF THE PREP CASCADE AND EDUCATIONAL RECOMMENDATIONS PrEP Cascade

Educational Recommendations

Identify populations at risk for HIV

» Utilize health services research projects to familiarize students and residents with population and individual risk.

Identify PrEP candidate

» Create algorithms in Electronic Health Record (EHR) systems to identify those at high risk for HIV. » Increase community knowledge of PrEP through educational materials, and PrEP testimonials from PrEP users.

Train medical students about PrEP prescription

» Address student bias/cultural competence regarding risk populations. Increase student/resident knowledge of PrEP. » Utilize HIV specialist knowledge to train medical students about pharmacology, anti-retro viral therapy, and side effects. » Teach students to conduct culturally appropriate sexual risk history. » Increase sexual risk assessment training, make standard of care in teaching hospitals. » Develop behavioral intervention to increase PrEP interest.

Link to PrEP

» Teach students how to prescribe PrEP. » Allow students to shadow PrEP delivery sessions. » Develop simulated patient encounters to develop student skills in PrEP prescription and adherence.

Initiate PrEP prescription

» Teach students to assess patients for medical assistance program eligibility.

Track PrEP adherence

» Utilize PrEP navigators and other support staff to track retention. » Introduce patient interactive messaging to residents and students as a means to improve adherence.

Achieve adherence and persistence

» Train students to monitor adherence via self-reported adherence measures as standard care. » Increase substance abuse and mental health screening, and referral, perhaps using Screening, Brief Intervention and Referral to Treatment (SBIRT) type models.

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REFERENCES 1. Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 2006-2009. PLoS One. 2011;6(8):e17502. http://dx.doi. org/10.1371/journal. pone.0017502. 2. Spinner CD, Boesecke C, Zink A, et al. HIV pre-exposure prophylaxis (PrEP): a review of current knowledge of oral systemic HIV PrEP in humans. Infection. 2016;44(2):151–158. http://dx.doi.org/10.1007/s15010-015-0850-2. 3. Anderson, P.L., Glidden, D.V., Liu, et al. (2012). Emitricitabinetenofivir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Science Translational Medicine, 4(151). http://dx.doi.org /10.1126/ scitranslmed.3004006. 4. Grant RM, Anderson PL, McMahan V, et al. Uptake of preexposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis. 2014;14 (9):820–829. http:// dx.doi.org/10.1016/S1473-3099(14)70847-3. 5. Bush S, Magnuson D, Rawlings M, Hawkins T, McCallister S, Giler RM. Racial characteristics of FTC/TDF for pre-exposure prophylaxis users in the U.S. Paper presented at: ASM Microbe Boston, MA, 2016. 6. Baeten J, Celum C (2011) Antiretroviral preexposure prophylaxis for HIV-1 prevention among heterosexual African men and women: the Partners PrEP study. 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention. Rome. 7. Abdool Karim Q, Abdool Karim SS, Frohlich JA, Grobler AC, Baxter C, et al. (2010) Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science 329: 1168–1174. 8. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, et al. (2010) Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. New England Journal of Medicine 363: 2587–2599. 9. Peterson L, Taylor D, Roddy R, Belai G, Phillips P, et al. (2007) Tenofovir disoproxil fumarate for prevention of HIV infection in women: a phase 2, double-blind, randomized, placebocontrolled trial. PLoS Clinical Trials 2: e27. 10. Thigpen MC, Kebaabetswe PM, Paxton LA,Smith DK, Rose

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CE, et al. (2012) Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. New England Journal of Medicine 367: 423–434. 11. Van Damme L, Corneli A, Ahmed K, Agot K, Lombaard J, et al. (2012). Preexposure Prophylaxis for HIV Infection among African Women. New England Journal of Medicine 367: 411–422. 12. Choopanya K, Martin M, Suntharasamai P, Sangkum U, Mock PA, et al. (2013). Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebocontrolled phase 3 trial. The Lancet 381: 2083–2090. 13. Jiang, J., Yang, X., Ye, L., Zhou, B., Ning, C., Huang, J., . . . Liang, H. (2014). Pre-exposure prophylaxis for the prevention of HIV infection in high risk populations: A meta-analysis of randomized controlled trials. PloS One, 9(2), e87674. doi:10.1371/journal.pone.0087674 [doi] 14. Okwundu CI, Uthman OA, Okoromah CA (2012). Antiretroviral pre-exposure prophylaxis (PrEP) for preventing HIV in high-risk individuals. Cochrane Database Systematic Review 7: CD007189. 15. Campbell JD, Herbst JH, Koppenhaver RT, Smith DK. (2013). Antiretroviral prophylaxis for sexual and injection drug use acquisition of HIV. American Journal of Preventive Medicine, 44(1S2):S63–S69. 16. Koenig, L.J., Lyles, C., & Smith, D.K. (2013). Adherence to antiretroviral medications for HIV pre-exposure prophylaxis: Lessons learned from trials and treatment studies. American Journal of Preventive Medicine, 44(IS2), S91-S98. 17. Ware NC, Wyatt MA, Haberer JE, et al. (2012). What’s love got to do with it? Explaining adherence to oral antiretroviral pre-exposure prophylaxis for HIV-serodiscordant couples. Journal of Acquired Immune Defıciency Syndrome, 59(5):463– 468. 18. Introducing Wicked Issues for HIV Pre-Exposure Prophylaxis Implementation in the U.S. 19. U.S. CDC. HIV Surveillance Report; CDC: Atlanta, GA, USA, 2011. 20. U.S. CDC. HIV Surveillance Report; CDC: Atlanta, GA, USA, 2013.

5th Annual Communities of Practice Conference 21. U.S. CDC. HIV Surveillance Supplemental Report; CDC: Atlanta, GA, USA, 2013. 22. Wilson EC, Garofalo R, Harris RD, et al. (2009).Transgender Female Youth and Sex Work: HIV Risk and a Comparison of Life Factors Related to Engagement in Sex Work. AIDS and Behavior, 13, 902–913. [PubMed: 19199022] 23. Garofalo R, Deleon J, Osmer E, Doll M, Harper GW (2006). Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 38(3):230–236. [PubMed: 16488820] 24. Huang, M. B., Ye, L., Liang, B. Y., Ning, C. Y., Roth, W. W., Jiang, J. J., . . . Bond, V. C. (2015). Characterizing the HIV/ AIDS epidemic in the united states and china. International Journal of Environmental Research and Public Health, 13(1),10.3390/ijerph13010030. doi:10.3390/ijerph13010030 [doi] 25. Strathdee SA, Stockman JK. Epidemiology of HIV among injecting and noninjecting drug users: current trends and implications for interventions. Curr HIV/AIDS Rep. 2010;7(2):99106. 26. Choopanya K, Martin M, Suntharasamai P, Sangkum U, Mock PA, Leethochawalit M, et al. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet. 2013;381(9883): 208390. 27. Mathers BM, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick RP, et al. HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage. Lancet. 2010; 375(9719):101428. 28. Strathdee SA, Shoptaw S, Dyer TP, Quan VM, Aramrattana A. Towards combination HIV prevention for injection drug users: addressing addictophobia, apathy and inattention. Curr Opin HIV AIDS. 2012;7(4):3205. 29. Centers for Disease Control and Prevention. Diagnoses of HIV infection in the United States and dependent areas; 2015. Available from: https://www.cdc.gov/hiv/statistics/ overview/ataglance.html. Accessed April 5, 2017. 30. Fonner VA, Dalglish SL, Kennedy CE, et al. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. AIDS. 2016;30(12):1973–1983. 31. Van Damme L, Corneli A, Ahmed K, et al. Preexposure prophylaxis for HIV infection among African women. N Engl J Med. 2012;367(5):411–422. 32. Marrazzo JM, Ramjee G, Richardson BA, et al. Tenofovirbased pre-exposure prophylaxis for HIV infection among African women. N Engl J Med. 2015;372(6):509–518. 33. Krakower D.S, Maloney K.M, Grasso C, Melbourne K, Mayer K.H. Primary care clinicians’ experiences prescribing HIV pre-exposure prophylaxis at a specialized community health centre in Boston: lessons from early adopters. Journal of the International AIDS Society 2016, 19:21165

Year 1 Research Projects 34. Tellalian D, Maznavi K, Bredeek U.F, Hardy D. Pre-Exposure Prophylaxis (PrEP) for HIV Infection: Results of a Survey of HIV Healthcare Providers Evaluating Their Knowledge, Attitudes, and Prescribing Practices. AIDS Patient Care and STDs 2013 27, 553-559. doi: 10.1089/apc.2013.0173 35. White J.M, Mimiaga M.J, Krakower D.S, Mayer K.H. Evolution of Massachusetts Physician Attitudes, Knowledge, and Experience Regarding the Use of Antiretrovirals for HIV Prevention. AIDS Patient Care and STDs 2012 26 395-405. doi: 10.1089/apc.2012.0030 36. Mimiaga M.J., White J.M, Krakower D.S, Biello K.B, Mayer K.H. Suboptimal awareness and comprehension of published pre-exposure prophylaxis efficacy results among physicians in Massachusetts. AIDS Care 2014; 26(6)684-693. Doi:10.1080/ 09540121.2013.845289 37. Karakower D.S, Oldenburg C.E, Mitty J.A, Wilson I.B, Kirth A.E, Maloney K.M…Mayer K.H. Knowledge, Beliefs and Practices Regarding Antiretroviral Medications for HIV Prevention: Results from a Survey of Healthcare Providers in New England. PLoSONE. 2015 10(7) doi: 10.1371/journal. pone.0132398 38. Castel A.D, Feaster D.J, Tang W, Willis S, Jordan H, Villamizar K… Metsch L. Understanding HIV Care Provider Attitudes Regarding Intentions to Prescribe PrEP. Journal of Acquired Immune Deficiency Syndrome. 2015 70(5) 520-528. Doi: 10.1097/QAI.0000000000000780 39. Adams L.M, Balderson B.H. HIV Providers’ Likelihood to Prescribe Pre-exposure Prophylaxis (PrEP) for HIV Prevention Differs By Patient Type: A Short Report. AIDS Care. 2016 28(9) 1154-1158. Doi: 10.1080/09540121.2016.1153595 40. Bacon O, Gonzalez R, Andrew E, Potter M.B, Iniguez J R, Cohen S.E…Fuchs J.D. Informing Strategies to Build PrEP Capacity Among San Francisco Bay Area Clinicians. J Acquir Immune Defic Syndr. 2017;7;74:175—179 41. Walsh J.L, Petrol A.E. Factors Related to Pre-exposure Prophylaxis Prescription by U.S. Primary Care Physicians. American Journal of Preventive Medicine. 2017;52(6):e165-e072 42. Hakre S, Blaylock J.M, Dawson P, Beckett C, Garges E.C, Michael N.L… Olulicz J.F. Knowledge, attitudes, and beliefs about HIV pre-exposure prophylaxis among US Air Force Health Care Providers. Medicine. 2016 95:32(e4511) 43. Blackstock O.J, Moore B.A, Berkenblit G.V, Calabrese S.K, Cunningham C.O, Fiellin D.A… Edelman E.J. A CrossSectional Online Survey of HIV Pre-Exposure Prophylaxis Adoption Among Primary Care Physicians. J Gent Intern Med. 2016 32(1):62-70. Doi: 10.1007/s11606-016-3903-z 44. Smith D.K, Mendoza M.C.B, Stryker J.E, Rose C.E. PrEP Awareness and Attitudes in a National Survey of Primary Care Clinicians in the United States 2009-2015. PLoSONE. 11(6):e0156592. Doi: 10.1371/journal.pone.0156592 45. Petroll A.E, Walsh J.L, Owczarzak J.L, McAuliffe T.L, Bogart L.M, Kelly J.A. PrEP Awareness, Familiarity, Comfort, and Prescribing Experiences among US Primary Care Providers and HIV Specialists. AIDS Behav. 2017. 21:1256-1267. DOI

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Year 1 Research Projects 10.1007/s10461-016-1625-1 46. Edelman E.J, Moore B.A, Calabrese S.K, Berkenblit G, Cunningham C, Patel V, Phillips K… Blackstock O. Primary Care Physicians’ Willingness to Prescribe HIV Pre-exposure Prophylaxis for People who Inject Drugs. 47. Karris M.Y, Beekmann S.E, Mehta S.R, Anderson C.M, Polgreen P.M. 48. Hoffman S, Guidry J.A, Collier K.L, Mantell J.E, BroccherLattimore D, Kaighobadi F, Sandfot T.G.M. A Clinical Home for Pre Exposure Prophylaxis (PrEP): Diverse Health Care Providers’ Perspectives on the “Purview Paradox”. J Int Assoc Provid AIDS Care. 2016. 15(1):59-65. Doi: 10.1177/2325957415600798. 49. Arnold E.A, Hazelton P, Lane T, Christopoulos K.A, Galindo G.R, Steward W.T, Moring S.F. A Qualitative Study of Provider Thoughts on Implementing Pre-Exposure Prophylaxis (PrEP) in Clinical Settings to Prevent HIV Infection. PLos ONE. 2012. 7(7):e40603. Doi: 10.1371/journal.pone.0040603. 50. Krakower D.S, Ware N.C, Maloney K.M, Wilson I.B, Wong J.B, Mayer K.H. Differing Experiences with Pre-Exposure Prophylaxis in Boston Among Lesbian, Gay, Bisexual, and Transgender Specialists and Generalists in Primary Care: Implications for Scale-Up. AIDS Patient Care and STDS. 2017. 31(7). Doi: 10.1089/apc.2017.0031. 51. Blumenthal J, Jain S, Krakower D, Sun X, Young J, Mayer K, Haubrich R. Kowledge is Power! Increase Provider Knowledge Scores regarding Pre-exposure Prophylaxis (PrEP) are Associated with Higher Rates of PrEP Prescription and Future Intent to Prescribe PrEP. AIDS Behav. 2015 May; 19(5): 802-810. doi: 10.1007/s10461-015-0996-z. 52. Finocchario-Kessler S, Champassak S, Hoyt M.J, Short W, Chakraborty R, Weber S… Anderson J. Pre-Exposure Prophylaxis (PrEP) for Safer Conception Among Serodifferent Couples: Findings from Healthcare Providers Serving Patients with HIV in Seven US Cities. AIDS Patients Care and STDs. (2016). 30(3). Doi:10.1089.apc.20150268. 53. Calabrese S.K, Magnus M, Mayer K.H, Krakower D.S, Eldahan A.I, Gaston L.A…Dovidio J.F. “Support Your Client at the Space That They’re in”: HIV Pre-Exposure Prophylaxis (PrEP) Prescribers’ Perspectives on PrEP- Related Risk Compensation. AIDS Patient Care and STDs. (2017). 31(4). Doi: 10.1089.apc.2017.0002. 54. Fortin, M., Stewart, M., Poitras, Marie-Eve, Almirall, J., & Maddocks, H. (2012). A systematic review of prevalence studies on multimorbidity: Toward a more uniform methodology. Annals of Family Medicine, 10(2). 55. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32 item checklist for interviews and focus groups. Int J Qual Health Care. 2007; 19(6): 349-357. 56. Liu, A.; Colfax, G.; Cohen, S.; Bacon, O.; Kolber, M.; Amico, KR., et al., editors. 7th International conference on HIV treatment and prevention adherence. Florida: Miami Beach; 2012. The spectrum of engagement in HIV prevention: proposal for a PrEP cascade. 57. von Elm, E., Altman,D.G., Egger, M., Pocock, S.J., Gotzsche, P.C., & Vandenbroucke, J.P. (2007). The Strengthening

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5th Annual Communities of Practice Conference the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Annals of Internal Medicine, 147(8), 573-577. 58. CDC. HIV and Injection Drug Use: Syringe Services Programs for HIV Prevention. Vital Signs. December 2016. 59. Reif S, Safley D, Wilson E, Whetten K. HIV/AIDS in the Southern US: Trends from 2008-2011 show a consistent disproportionate epidemic. http://southernaidsstrategy.org/ research/. Accessed July 25, 2014. 60. Reif S, Pence BW, Hall I, Hu X, Whetten K, Wilson E. HIV Diagnoses, prevalence and outcomes in nine Southern States J Community Health 2014 Dec 19. [Epub ahead of print]. 61. Quinn, G. P., Sanchez, J. A., Sutton, S. K., Vadaparampil, S. T., Nguyen, G. T., Green, B. L., … Schabath, M. B. (2015). Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations. CA: A Cancer Journal for Clinicians, 65(5), 384-400. doi:10.3322/caac.21288 [doi] 62. Conron KJ, Mimiaga MJ, Landers SJ. A population-based study of sexual orientation identity and gender differences in adult health. American Journal of Public Health. 2010;100(10):1953–1960. doi: 10.2105/AJPH.2009.174169. 63. Dilley JA, Simmons KW, Boysun MJ, Pizacani BA, Stark MJ. Demonstrating the importance and feasibility of including sexual orientation in public health surveys: Health disparities in the Pacific Northwest. American Journal of Public Health. 2010;100(3):460–467. doi: 10.2105/AJPH.2007.130336. 64. Fredriksen-Goldsen KI, Kim HJ, Barkan SE, Muraco A, HoyEllis CP (2013). Health disparities among lesbian, gay, and bisexual older adults: results from a population-based study. Am J Public Health, 103(10):1802-9. 65. Calabrese S.K, Earnshaw V.A, Underhill K, Hansen N.B, Dovidio J.F. The Impact of Patient Race on Clinical Decisions Related to Prescribing HIV Pre-Exposure Prophylaxis (PrEP): Assumptions About Sexual Risk Compensation and Implications for Access. AIDS Behav. 2014 February; 18(2): 226-240. doi: 10.1007/s10461-013-0675-x. 66. Lehman, D. A. and others. Risk of drug resistance among persons acquiring HIV within a randomized clinical trial of single- or dual-agent preexposure prophylaxis.Journal of Infectious Diseases. 2015. 67. Grant, R. M. & Liegler, T. Weighing the risk of drug resistance with the benefits of HIV preexposure prophylaxis. Journal of Infectious Diseases. Journal of Infectious Diseases. 2015. 68. Kalichman, S.C., Amaral, C.M., Swetzes, C., Jones, M., Macy, R., Kalichman, M.O., & Cherry, C. (2009). A simple single item rating scale to measure medication adherence: Further evidence for convergent validity. Journal of the International Physicians AIDS Care, 8(6), 367-374. doi:10.1177/1545109709352884[doi] 69. Cooper, R.L., Juarez P., Morris M., Edgerton R., Brown L.S., Ramesh A., Tabatabai M., Im, W., Arcury T.A., Mena L.,Collins, S., Juarez P.M. (2017). Training for Medical Students and Residents in the Administration of Pre-Exposure Prophylaxis: A Systematic Review (In preparation, 2018).

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YEAR 1 POLICY BRIEF

Medical Education Efforts to Reduce Implicit Physician Bias towards LGBTQ Patients EXECUTIVE SUMMARY BACKGROUND LGBTQ individuals experience higher rates of health disparities, which in part, are driven, by lack of cultural awareness, personal discomfort and/or explicit and implicit bias encountered and exhibited in the health care environment. Over the last three decades, there has been a growing recognition that biased attitudes and beliefs of health care providers towards LGBTQ patients in the healthcare system contribute to disparities through its impact on healthcare access and quality of clinical care1,2 Little is known about how medical students are trained to identify, confront, and reduce personal bias towards LGBTQ persons and other vulnerable populations. The aim of this study was to conduct a systematic review of the literature to assess how US medical schools are training students to identify and address implicit biases towards LGBTQ persons. The research question was shaped by input from our Community of Practice.

RECOMMENDATIONS Addressing physician implicit biases has the potential of transforming medical school education. Curricular changes are needed that address implicit biases among medical students towards LGBTQ persons and other vulnerable populations Bias awareness strategies were found to be more effective when practiced in a supportive and individualized learning environment such as a patient simulation that provides students with opportunities to receive direct feedback on perceived implicit biases while minimizing student defensiveness11.

ISSUE Research has found that with less time and limited information gathered from the electronic health record (EMR), physician’s behavior becomes increasingly governed by stereotypes and implicit biases12,13. Vulnerable populations, such as LGBTQ individuals often experience higher rates of health disparities, which in part, are driven, by lack of cultural awareness, personal discomfort and/or explicit and implicit bias encountered and exhibited in the health care environment. Little is known about how medical students are trained to identify, confront, and reduce personal bias towards LGBTQ persons and other vulnerable populations. The aim of this study was to conduct a systematic review of how US medical schools are training students to identify and address personal implicit biases towards LGBTQ persons. The research question was shaped by our Community of Practice.

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BACKGROUND LGBTQ patients have higher rates of anal cancer14, asthma, cardiovascular disease15-18, obesity16, substance abuse12,18,19, cigarette smoking20, and suicide13. Sexual minority women report fewer lifetime Pap tests21; transgender youth have less access to physical and mental health care22; and LGBTQ individuals are more likely to delay or avoid necessary medical care, compared to heterosexual individuals. These disparities have been attributed, in part, to lower health care utilization by LGBTQ individuals23,24. Perceived discrimination from physicians and denial of health care altogether are common experiences among LGBTQ patients and have been identified as contributing to disparities25,26. Implicit biases among health care providers towards LGBTQ persons have been linked to lower quality of care27-29, are rarely assessed30, and can be resistant to change. Previous studies that addressed physician implicit bias towards patients from racial/ethnic minority groups have found that implicit bias continues to persist despite an absence of negative explicit attitudes31. Even when providers make an explicit commitment to equitable care, implicit biases operating outside of their conscious awareness may undermine that commitment. The disparities in access to care and health outcomes often are compounded by vulnerabilities linked to gender, racial identity32-34 and geographic location35.The percentage of the LGBTQ population lacking a regular primary care provider is significantly higher than among heterosexuals (30% versus 10%, respectively)24,36. One survey of health care providers found that over half expressed discomfort caring for LGBTQ patients37. The importance of physician implicit bias as a contributor to the health disparities that confront LGBTQ individuals is highlighted in professional competency objectives generated by the Association of American Medical Colleges Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development38. These competencies include the need for understanding that implicit LGBTQrelated bias may negatively impact interactions with patients and for including strategies to mitigate implicit bias in health care settings38. Training medical students to be aware of and how to address their own implicit biases towards LGBTQ persons and other vulnerable populations provides a critical opportunity for promoting equal access to quality health care and, ultimately, for eliminating health disparities.

RESULTS / KEY FINDINGS The systematic literature search yielded nine studies that assessed training programs to reduce LGBTQ-related bias in health care professions students and four studies that focused on health care providers. Studies ranged from small sample size (n = 13) to large (n = 848) and represented a wide range of health professions training programs including medicine (n = 6), nursing (n = 2) and dentistry (n = 1), as well as health care providers (n = 4). The programs varied in their delivery format (e.g., lecture, small group discussion, interactive theater workshop), frequency (range: 1 to 6 sessions) and duration (range: 45-minute lecture to 4-week web-based course). Programs designed to increase student or provider knowledge of the LGBTQ community and LGBTQ-relevant health care issues utilized lectures, readings, videos, interviews or presentations by LGBTQ individuals, and group discussion. Significant knowledge gains in knowledge were observed for students attending single-session41-44 and for students and providers attending more time-intensive program formats45, 46. One found that knowledge gains for medical students were maintained three months after the training program46. Programs designed to promote more positive student attitudes toward LGBTQ patients utilized perspective-taking exercises, videos of LGBTQ patients describing discrimination in health care settings, individual presentations, lectures, and LGBTQ patient panels. Strategies that reduce biases in students and providers are likely to increase access to care and reduce health disparities among vulnerable populations.

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DISCUSSION The present review provides direction for researchers and educators seeking to reduce implicit bias among medical students toward LGBTQ patients and other vulnerable populations and provides a blueprint that can be used to train students how to become aware of and address personal biases. While research on programs to reduce bias among medical students is limited, research with health professionals may shed light on the key ingredients of effective programs. This review found that comfort level regarding LGBTQ health care was increased through experiential learning, which is consistent with prior results found in health professions samples47. Once implicit biases have been identified, medical students can be taught strategies to reduce their potential impact on patient care39. Some of these strategies, such as perspective-taking and intergroup contact were identified in the present review as effective components of programs seeking to promote more positive explicit attitudes and greater comfort working with LGBTQ patients. Strategies that have received support for reducing implicit bias in other populations include: 1) the use of mindfulness meditation to promote nonjudgmental awareness48,49 2) individuation training to encourage providers to focus on individual attributes rather than group membership50; and 3) training in emotion regulation skills to reduce stress levels and negative emotions1,51. Although changes in implicit bias were not assessed using quantitative measures, anecdotal evidence from two studies found that an increase in awareness of implicit bias can be achieved among students41, 52. Future studies and medical school training programs should examine the influence of training on implicit LGBTQ-related bias.

LIMITATIONS Findings of the systematic review were limited as none addressed the long-term impact of implicit bias training on students’ behavior or on patient outcomes. Hence, we could only draw from the extant literature on implicit racial/ethnic bias reduction to generate recommendations for training to address implicit bias towards LGBTQ persons and other vulnerable populations3, 39, 40.

RECOMMENDATIONS / NEXT STEPS Curriculum changes targeting a reduction of implicit biases among medical students towards LGBTQ persons and other vulnerable populations is needed and offers the potential for transforming medical school education. Training activities and modalities that reduce bias towards LGBTQ persons and other vulnerable populations through increases in knowledge, explicit attitudes, and comfort level are supported by the present review. Results suggest that bias awareness strategies should be practiced in a supportive and individualized learning environment such as patient simulation that provides students with opportunities to receive direct feedback about perceived implicit biases while minimizing student defensiveness39. Towards this end, curricula should emphasize that implicit biases – whether negative or positive – are universal psychological phenomena51. While the Association of American Medical Colleges Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development has generated professional competency objectives, they currently are only advisory. Further steps towards incorporating professional competency objectives on reducing implicit bias towards LGBTQ and other vulnerable populations into accreditation standards of the Liaison Committee on Medical Education (LCME) should be considered.

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REFERENCES 1. Burgess D, van Ryn M, Dovidio J, Saha S. Reducing Racial Bias Among Health Care Providers: Lessons from SocialCognitive Psychology. Journal of General Internal Medicine. 2007;22(6):882-887. 2. Shavers VL. The state of research on racial/ethnic discrimination in the receipt of health care. Am J Public Health. 2012;102. 3. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):10061012. 4. Carabez R, Pellegrini M, Mankovitz A, Eliason MJ, Dariotis WM. Nursing students’ perceptions of their knowledge of lesbian, gay, bisexual, and transgender issues: effectiveness of a multi-purpose assignment in a public health nursing class. J Nurs Educ. 2015;54(1):50-53. 5. Strong KL, Folse VN. Assessing undergraduate nursing students’ knowledge, attitudes, and cultural competence in caring for lesbian, gay, bisexual, and transgender patients. J Nurs Educ. 2015;54(1):45-49. 6. Thomas DD, Safer JD. A Simple Intervention Raised ResidentPhysician Willingness to Assist Transgender Patients Seeking Hormone Therapy. Endocr Pract. 2015;21(10):1134-1142. 7. Hardacker CT, Rubinstein B, Hotton A, Houlberg M. Adding silver to the rainbow: the development of the nurses’ health education about LGBT elders (HEALE) cultural competency curriculum. J Nurs Manag. 2014;22(2):257-266. 8. Johnson K, Rullo J, Faubion S. Student-Initiated Sexual Health Selective as a Curricular Tool. Sex Med. 2015;3(2):118127. 9. Johnson TJ, Ellison AM, Dalembert G, et al. Implicit Bias in Pediatric Academic Medicine. Journal of the National Medical Association. 10. Bartos SE, Berger I, Hegarty P. Interventions to reduce sexual prejudice: a study-space analysis and meta-analytic review. J Sex Res. 2014;51(4):363-382. 11. Zestcott, C. A., Blair, I. V. & Stone, J. Examining the presence, consequences, and reduction of implicit bias in health care: A narrative review. Group Process Intergroup Relat. 2016. doi:10.1177/1368430216642029. 12. Williams EC, Bradley KA, Balderson BH, et al. Alcohol and associated characteristics among older persons living with human immunodeficiency virus on antiretroviral therapy. Subst Abus. 2014;35(3):245-253. 13. Remafedi G, French S, Story M, Resnick MD, Blum R. The relationship between suicide risk and sexual orientation: results of a population-based study. Am J Public Health. 1998;88(1):57-60. 14. Quinn GP, Sanchez JA, Sutton SK, et al. Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/ questioning (LGBTQ) populations. CA Cancer J Clin. 2015;65(5):384-400. 15. Conron KJ, Mimiaga MJ, Landers SJ. A Population-Based

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Study of Sexual Orientation Identity and Gender Differences in Adult Health. American Journal of Public Health. 2010;100(10):1953-1960. 16. Dilley JA, Simmons KW, Boysun MJ, Pizacani BA, Stark MJ. Demonstrating the Importance and Feasibility of Including Sexual Orientation in Public Health Surveys: Health Disparities in the Pacific Northwest. American Journal of Public Health. 2010;100(3):460-467. 17. Fredriksen-Goldsen KI, Kim H-J, Barkan SE, Muraco A, HoyEllis CP. Health Disparities Among Lesbian, Gay, and Bisexual Older Adults: Results From a Population-Based Study. American Journal of Public Health. 2013;103(10):1802-1809. 18. Bauermeister J, Eaton L, Stephenson R. A Multilevel Analysis of Neighborhood Socioeconomic Disadvantage and Transactional Sex with Casual Partners Among Young Men Who Have Sex with Men Living in Metro Detroit. Behav Med. 2016;42(3):197-204. 19. Smalley KB, Warren JC, Barefoot KN. Differences in Health Risk Behaviors Across Understudied LGBT Subgroups. Health Psychology. 2016;35(2):103-114. 20. Cochran SD, Bandiera FC, Mays VM. Sexual orientationrelated differences in tobacco use and secondhand smoke exposure among US adults aged 20 to 59 years: 2003-2010 National Health and Nutrition Examination Surveys. Am J Public Health. 2013;103(10):1837-1844. 21. Charlton BM, Corliss HL, Missmer SA, et al. Reproductive health screening disparities and sexual orientation in a cohort study of U.S. adolescent and young adult females. J Adolesc Health. 2011;49(5):505-510. 22. Haas AP, Eliason M, Mays VM, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: review and recommendations. J Homosex. 2011;58(1):10-51. 23. Buchmueller T, Carpenter CS. Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000-2007. Am J Public Health. 2010;100(3):489-495. 24. Heck JE, Sell RL, Gorin SS. Health care access among individuals involved in same-sex relationships. Am J Public Health. 2006;96(6):1111-1118. 25. Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Social Science & Medicine. 26. Grant JM, Mottet LA, Tanis J. National Transgender Discrimination Survey Report on Health and Health Care. Washington DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2010. 27. Burke SE, Dovidio JF, Przedworski JM, et al. Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People Among Heterosexual Medical Students? A Report from Medical Student CHANGES. Academic medicine : journal of the Association of American Medical Colleges. 2015;90(5):645-651.

5th Annual Communities of Practice Conference 28. Sabin JA, Riskind RG, Nosek BA. Health Care Providers’ Implicit and Explicit Attitudes Toward Lesbian Women and Gay Men. Am J Public Health. 2015;105(9):1831-1841. 29. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics. 2017;18:19. 30. Rowniak SR. Factors Related to Homophobia Among Nursing Students. J Homosex. 2015;62(9):1228-1240. 31. Blair IV, Havranek EP, Price DW, et al. Assessment of Biases Against Latinos and African Americans Among Primary Care Providers and Community Members. American Journal of Public Health. 2012;103(1):92-98. 32. Sullivan PS, Rosenberg ES, Sanchez TH, et al. Explaining racial disparities in HIV incidence in black and white men who have sex with men in Atlanta, GA: a prospective observational cohort study. Annals of epidemiology. 2015;25(6):445-454. 33. Millett GA, Peterson JL, Flores SA, et al. Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a metaanalysis. Lancet. 2012;380(9839):341-348. 34. Mereish EH, Bradford JB. Intersecting Identities and Substance Use Problems: Sexual Orientation, Gender, Race, and Lifetime Substance Use Problems. Journal of Studies on Alcohol and Drugs. 2014;75(1):179-188. 35. Torres CG, Renfrew M, Kenst K, Tan-McGrory A, Betancourt JR, Lopez L. Improving transgender health by building safe clinical environments that promote existing resilience: Results from a qualitative analysis of providers. Bmc Pediatrics. 2015;15. 36. Kamen C, Palesh O, Gerry AA, et al. Disparities in Health Risk Behavior and Psychological Distress Among Gay Versus Heterosexual Male Cancer Survivors. Lgbt Health. 2014;1(2):86-U103. 37. Khan A, Plummer D, Hussain R, Minichiello V. Does physician bias affect the quality of care they deliver? Evidence in the care of sexually transmitted infections. Sexually Transmitted Infections. 2008;84(2):150-151. 38. AAMC Advisory Committee on Sexual Orientation GI, and Sex Development,. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born with DSD: A Resource for Medical Educators. 2014. 39. Zestcott CA, Blair IV, Stone J. Examining the Presence, Consequences, and Reduction of Implicit Bias in Health Care: A Narrative Review. Group processes & intergroup relations : GPIR. 2016;19(4):528-42. doi:10.1177/1368430216642029 40. Valverde EE, DiNenno EA, Schulden JD, Oster A, Painter T. Sexually transmitted infection diagnoses among Hispanic immigrant and migrant men who have sex with men in the United States. International Journal of Std & Aids. 2016;27(13):1162-9. doi:10.1177/0956462415610679 41. Carabez R, Pellegrini M, Mankovitz A, Eliason MJ, Dariotis WM. Nursing students’ perceptions of their knowledge of lesbian, gay, bisexual, and transgender issues: effectiveness

Year 1 Research Projects of a multi-purpose assignment in a public health nursing class. The Journal of nursing education. 2015;54(1):50-3. doi:10.3928/01484834-20141228-03 42. Eriksson SE, Safer JD. Evidence-Based Curricular Content Improves Student Knowledge and Changes Attitudes Towards Transgender Medicine. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2016;22(7):837-41. doi:10.4158/EP151141.OR 43. Strong KL, Folse VN. Assessing undergraduate nursing students’ knowledge, attitudes, and cultural competence in caring for lesbian, gay, bisexual, and transgender patients. The Journal of nursing education. 2015;54(1):45-9. doi:10.3928/01484834-20141224-07 44. Thomas D.D., Safer J.D. A Simple Intervention Raised Resident-Physician Willingness to Assist Transgender Patients Seeking Hormone Therapy. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2015;21(10):1134-42. doi:10.4158/EP15777.OR 45. Hardacker CT, Rubinstein B, Hotton A, Houlberg M. Adding silver to the rainbow: the development of the nurses’ health education about LGBT elders (HEALE) cultural competency curriculum. Journal of nursing management. 2014;22(2):25766. doi:10.1111/jonm.12125 46. Johnson K, Rullo J, Faubion S. Student-Initiated Sexual Health Selective as a Curricular Tool. Sexual medicine. 2015;3(2):118-27. doi:10.1002/sm2.57 47. Turner RN, Crisp RJ, Lambert E. Imagining intergroup contact can improve intergroup attitudes. Group Process Intergroup Relat. 2007;10(4):427-41. doi:10.1177/1368430207081533 48. Lueke A, Gibson B. Mindfulness Meditation Reduces Implicit Age and Race Bias: The Role of Reduced Automaticity of Responding. Soc. Psychol. Personal Sci. 2015;6(3):284-91. doi:10.1177/1948550614559651 49. Stell AJ, Farsides T. Brief loving-kindness meditation reduces racial bias, mediated by positive other-regarding emotions. Motiv. Emot. 2016;40(1):140-7. doi:10.1007/s11031-015-9514-x 50. Stone J, Moskowitz GB. Non-conscious bias in medical decision making: what can be done to reduce it? Medical education. 2011;45(8):768-76. doi:10.1111/j.13652923.2011.04026.x 51. Kirwan Institute. State of the Science: Implicit Bias Review 2016. 2016. 52. Kelley L, Chou CL, Dibble SL, Robertson PA. A critical intervention in lesbian, gay, bisexual, and transgender health: knowledge and attitude outcomes among secondyear medical students. Teaching and learning in medicine. 2008;20(3):248-53. doi:10.1080/10401330802199567

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Medical Education Efforts to Increase Pre-Exposure Prophylaxis among High Risk Populations BACKGROUND Treatment adherence has been demonstrated to both improve the health outcomes of individuals infected with HIV and prevent the transmission of the virus to others. Of all racial/ethnic groups, African American men incur the highest risk of becoming infected with HIV and suffering poor health outcomes once infected. However, little is known about the differences in treatment adherence between HIV+ African American men who have sex with men (MSM) and HIV+ African American men who have sex with women (MSW). We compared the differences in behaviors and social determinants of health among African American MSM and African American MSW. The study results yield implications for modifying how primary care professionals intervene in the HIV care cascade to address the unique needs of each group. The study results can inform medical education, residency training, and clinical practice in primary care.

METHODS We matched a data set from a matched sample of African American MSM and MSW (n=40). The data was collected as part of a social determinants of a health study of clinic patients with an administrative data set drawn from CAREWare of 242 biologically born males. The social determinants (matched) dataset was used to compare social determinants of health and behaviors of MSM and MSW. Differences in lost to care rates between these two populations were also examined. The CAREWare data set was used to compare the HIV treatment outcomes between African American MSM and MSW.

RESULTS MSM were significantly younger than their MSW counter parts in our clinic data. There were no significant differences found in the social determinants of health, rates of drug use, stigma, mental health, discrimination, stress, nor income. However, MSM were more likely to have experienced sexual assault than their heterosexual counterparts. (X2 = 4.33, p < .05) (n = 40). In the CAREWare data set, we observed a significant difference in viral suppression rates between African American MSM and African American MSW: 53.2% of MSM reported viral suppression compared to 63.2% of MSW (X2 = 2.94, p < .05) (n = 242). Additionally, rates of those who had converted to AIDS (CDC definition) were significantly higher among MSM than MSW (X2 = 3.49, p < .05), (n = 242).

RECOMMENDATIONS Our study findings suggest that the HIV Care Cascade may need to be tailored to address the unique needs of African American MSM and MSW populations through the patient-centered medical home (PCMH). The MSM population was younger and more likely to have experienced sexual trauma than MSW. Either or both factors may need to be addressed to increase treatment adherence to the HIV Care Cascade, improve health outcomes among African American MSM, and improve knowledge and skills for primary care physicians. Further, the findings suggest that enhancing cultural competency among physicians and increasing trauma informed care training in the primary care curriculum of medical students and residents is essential to improving health outcomes for this population.

KEY STAKEHOLDERS Key stakeholders include, but are not limited to, academic medical institutions, medical education accreditation bodies, health care providers, advocacy groups, public health officials, policymakers, health professions associations, and populations at risk.

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YEAR 2 SYSTEMATIC REVIEW

Screening and Health Care Services for Adverse Childhood Experiences in Vulnerable Populations in Primary Care Settings DESCRIPTION The aim of this research is to identify and assess the extent to which medical students are taught about adverse childhood experiences (ACEs): screening, treatment, community referrals and their impact on personal health and health disparities in primary care settings. Based on this aim, we pose several research questions to be answered through systematic review of the literature, curricula, and student surveys about how medical schools are preparing students to address the effects of ACEs, with a focus on vulnerable populations. We will disseminate findings through scholarly presentations at graduate medical education conferences and meetings, peer reviewed publications, our community of practice, and a policy brief and provide technical assistance to programs on how to incorporate ACES in their curriculum and respond to the needs of vulnerable populations. Statement of the problem gaps in current research: Increasingly, studies are showing that adverse childhood experiences (ACEs) affect the health f persons as they age. Yet, there is paucity of information in the literature regarding strategies to teach medical students how to screen for ACEs and be responsive to the needs of vulnerable populations that are impacted by ACEs. While there is a growing body of research that supports a dose-response relationship between number of ACEs experienced during childhood and a range of adverse health outcomes of adulthood, especially among vulnerable populations, relatively little is known about the extent to which medical students are being taught about the effects of ACEs on the health of vulnerable populations, including LGBTq populations, homeless persons and, migrant farm workers, and how to screen for and care for those who have multiple exposures. To date, little systematic attention has been given to ensuring future primary health care providers are trained to screen for ACEs, undertake interventions that can improve long term health outcomes later in life, or refer patients to community resources that can lead improvements in health and healthcare.

RESEARCH QUESTIONS » What evidence exists regarding what and how medical students are being taught about ACEs: what they are, what impact they have later in life, how they affect vulnerable populations, and what skills they are being taught to help students address them? » What are the core elements of the medical educational curriculum that can be revised and adapted to ensure students have the knowledge and skills to provide culturally competent health care for vulnerable populations exposed to ACEs?

PROJECT GOALS » To identify the extent to which medical students are trained to screen, treat, or refer persons exposed to ACEs in primary care settings. » To identify and/or develop model curricular elements that can be used by other medical schools to prepare students to effectively address the needs of vulnerable populations exposed to ACEs. » To disseminate research results and curricular modules on how medical schools are addressing ACEs in vulnerable populations to graduate medical education audiences.

OBJECTIVES » Provide direct feedback and consensus from content experts on the adequacy of the primary care research training process using evidence-based studies, data, and methodologies. » Determine the effectiveness and efficacy of the studies, results, findings, and products to inform curricular change in medical education in treating vulnerable populations that focus on continuing quality of care, team building and value-based pricing.

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YEAR 2 SYSTEMATIC REVIEW

Screening & Health Care Services for Vulnerable Populations Exposed to Interpersonal Violence across the Life Course DESCRIPTION This research project will assess the extent to which medical schools prepare students to address the needs of vulnerable populations exposed to interpersonal violence across the life course in primary care settings. It will employ multiple methods to assess current medical school educational practice, identify evidence-based best practices, develop and recommend curricular modifications, and disseminate information to the broader medical education profession through presentations at professional meetings, policy briefs, and articles in peer reviewed journals. Statement of the problem gaps in current research: Interpersonal violence (IV) is “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, stunted emotional development, or deprivation. IV occurs across the life course and threatens the life, health and happiness of thousands of persons each year in the United States. IV encompasses a wide range of incidents from child abuse and neglect by caregivers, youth violence (violence by adolescents and young adults aged 10 to 29 years), intimate partner violence, sexual violence, elder abuse, and gun violence. There is a limited evidence base regarding best strategies in teaching medical students how to screen for and address the needs of vulnerable populations affected by interpersonal violence. It is important that medical students understand and are prepared to take steps to address underlying individual, interpersonal, community and societal-level factors that increase the risk for interpersonal violence across the life course among of vulnerable populations. This research project will assess the extent to which medical students are taught about the needs of vulnerable populations and the skills to screen, care, and refer those exposed to interpersonal violence across the life course in primary care.

RESEARCH QUESTIONS » What is the evidence base regarding education of medical students on screening for interpersonal violence across the life course among vulnerable populations for medical students in primary care settings? » What are the core elements of the medical educational curriculum that can be revised and adapted to ensure students have the knowledge and skills to provide culturally competent health care for vulnerable populations exposed to interpersonal violence across the life course?

PROJECT GOALS » To identify the extent to which medical students are trained to screen, treat, or refer persons exposed to interpersonal violence across the life course. » To develop model curricular elements that can be used by other medical schools to prepare students to effectively address the needs of vulnerable populations exposed to violence at different stages of life. » To disseminate research results on how medical schools are addressing exposure to interpersonal violence across the life course in vulnerable populations to graduate medical education audiences.

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Addressing Adverse Childhood Experiences in Medical Education Curriculum Authors: Paul D. Juarez, Michael Paul, Aramandla Ramesh, & Patricia Matthews-Juarez, PhD

EXECUTIVE SUMMARY It is estimated that ACEs affect 20%–50% of adults and are associated with considerable adult chronic disease, unhealthy behavior, mental health conditions, early mortality, violence victimization and perpetration, and overall quality of life. ACEs include seven categories of childhood exposure, including three types of abuse: psychological abuse, physical abuse, sexual abuse; and four types of household dysfunction: substance abuse, mental illness, mother treated violently, and criminal behavior in the household. Vulnerable populations, such as migrant farmworkers, persons experiencing homelessness, and LGBTQ persons often experience multiple traumatic events early in their lives that put them at increased risk for experiencing ACEs and increased risk for multiple associated adverse health and mental health outcomes as they age. Yet, screening for ACEs and provision of trauma-informed care (TIC) are not yet part of standard medical care or medical education. The aim of this research was to identify and assess the extent to which medical students are taught about ACEs, ACEs screening, and trauma informed care. » ACEs include seven categories of childhood exposure, including three types of abuse: psychological abuse, physical abuse, sexual abuse; and four types of household dysfunction: substance abuse, mental illness, mother treated violently, and criminal behavior in the household. » Research on the biological consequences of ACEs on children has demonstrated lasting alterations to the endocrine, autonomic, and central nervous system. » ACEs occur early in life but have effects, which without intervention, can last a lifetime. » Persons exposed to ACEs are at increased risk for multiple adverse health and mental health outcomes and poorer quality of life as they age. » It is estimated that ACEs affect 20%–50% of adults. » Vulnerable populations, such as migrant farmworkers, persons experiencing homelessness, and LGBT persons are at increased risk for adverse childhood experiences. » Trauma informed care (TIC) is a promising approach that has been proposed to address ACEs. TIC has been shown to promote the provision of better inter-professional health care and higher compliance with health treatment plans. » A history of complex trauma will require the integration of behavioral health specialists as members of the primary health care team. » ACEs screening TIC are not yet part of standard medical education.

BACKGROUND A growing body of research has attributed the adverse health consequences of ACEs to “lasting alterations to the endocrine, autonomic, and central nervous system” during early childhood. The core problems underlying ACEs are affect dysregulation, structural dissociation, somatic dysregulation, impaired self-development and disorganized attachment, regardless of the specific diagnosis or assessment and treatment methodologies in use.1 Adverse health outcomes that have been associated with ACEs include: alcoholism and alcohol abuse, chronic obstructive pulmonary disease, cardio-metabolic disease, depression, fetal death, early initiation of sexual activity, illicit drug use, risk for intimate partner violence, liver disease, sexually transmitted diseases, smoking, suicide attempts, and unintended pregnancies. Yet, ACEs research results have yet to be translated into clinical practice. Physicians typically are trained to address a behavior, like smoking, or to treat a disease like cardiovascular disease, without consideration of the underlying causes. The majority of primary care providers are not knowledgeable about ACEs, lack understanding of how to screen for ACEs reported by children or family members, and are ill equipped on how to respond. As a group, patients with a history of complex trauma disorders have developmental/attachment deficits that require additional treatment goals that are more extensive than those directed at PTSD symptoms alone. TIC is a strength-based, life course approach used to identify and respond to the needs of patients who have been exposed to multiple and/or complex trauma, such as ACEs. TIC views symptoms as expected and adaptive reactions to traumatic childhood. Core

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principles of trauma-informed care are `safety’, `trustworthiness’, `choice’, `collaboration’, and `empowerment’2. TIC recommends that the effects of trauma on the brain, body and subsequent functioning underlies a significant component of effective trauma therapy experiences and form part of patient psycho-education. TIC requires culturally competent providers who are sensitive to gender, sexual orientation, ethnicity, age, and other patient differences and highly attuned to their own responses to cultural, gender and other `differences’ in relation to their clients. Lack of attention to ACEs by physicians is attributed to a lack of training, familiarity with ACEs screening, and knowledge about how to respond when positive results are found. Failure to screen for ACEs leaves opportunities to improve health missed. Fortunately, patient centered medical homes which provide access to mental health clinicians and behaviorist teams are increasing primary care capacity to help patients and family physicians care for patients with ACE histories and improve patient quality of life.

METHODS RESEARCH QUESTIONS Our research sought to assess the extent to which medical students are taught about the impact of ACEs among vulnerable populations, how to screen for ACEs, and how to respond. » What literature exists regarding what and how medical students are being taught about ACEs: what they are, what impact they have across the life course, how they affect vulnerable populations, and what skills they are being taught to help students address them? » What are the core components of ACEs educational content that medical student education needs to cover? » What evidence exists of the impact of physicians in addressing ACEs?

PROCEDURES We conducted a systematic review seven databases to assess the strength of the evidence for screening and treating the effects of ACEs in general and on vulnerable populations, in particular. The databases that were searched included: PubMed, ERIC, SCOPUS, Web of Science, OVID, CINAHL, and Psych INFO. After searching the seven databases, 715 references were found. These references were downloaded and entered into the citation manager, RefWorks. In RefWorks we removed the exact and close duplicates (n=89), 626 references remained. Since we were primarily concerned with journal articles, we removed books (n=56), conference proceedings (n=3), and dissertations (n=3). This left 564 articles to review. After reviewing the title and abstract for the 564 references, results were narrowed down to 16 relevant articles. In addition, we assessed the literature to see if there was evidence that students were being prepared to screen for and address ACEs among vulnerable populations, including LGBTQ, persons experiencing homelessness, and migrant farm workers. Only two studies were found that addressed using a trauma informed care approach with persons experiencing homelessness and one with LGBTQ youth.

RESULTS/KEY FINDINGS Results of the systematic review found little evidence that ACEs screening and trauma informed care have been incorporated into the standard, undergraduate medical education curriculum. While there is a growing support for the need to train medical and other health care providers3, behavioral health and social service care providers4-8 to address ACES, only a few articles were identified in the literature that reviewed actual efforts to train primary care providers9-18. Of those, only two addressed the needs of medical students13,17, one in residency training programs18, and six among primary care providers9-12,15,16. Of the two studies that addressed medical students, only one was a research study that assessed the impact of a brief course on ACEs knowledge. While the study yielded promising results, findings were limited by a convenience sample of 20 medical students.

DISCUSSION While research suggests a dose-response relationship between number of ACEs experienced during childhood and a range of adverse health outcomes of adulthood, especially among vulnerable populations, study results found little evidence to suggest that medical schools are addressing ACEs in their curriculum. In addition, no studies have been conducted either in primary care settings to assess the impact of using a TIC to address ACEs in vulnerable populations, including persons experiencing homelessness, LGBTQ persons, or migrant farmworkers. Research findings on the effect of ACEs across the life course have not yet been translated into clinical practice or medical education. Only two articles were identified in the research literature that assessed the impact of teaching medical students about the effects of ACEs and none which identified how TIC can be used to screen or care for the complex needs of vulnerable populations, including LGBT, homeless persons and, migrant workers.

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Failures in the health care system occur when complex trauma and its effects are unrecognized or misdiagnosed, and services do not address trauma victims’ needs. People impacted by trauma characteristically present to multiple services over a long period of time and care is often fragmented with inadequate coordination between services, and poor referral pathways and follow-up protocols which results in unintegrated care. Understanding that trauma underpins the way in which many people present who attend a diversity of service settings necessitates substantially new ways of operating. There is an emerging body of evidence that suggests that the bio-physiological response to complex trauma can be prevented or mitigated by a supportive and empowering trauma informed care environment. Two papers looked at the implications of using a trauma informed care approach to working with persons experiences homelessness10,19 and one with LGBTQ youth20 but were not research papers. However, the systematic review has enabled us to make recommendations for a model ACEs screening protocol and trauma informed care approach for teaching medical students. When ACEs screening indicates that further assessment is needed, the clinician should warmly but directly investigate the client’s trauma history and formulate a trauma-informed treatment plan. It is critical that clinicians be aware of co-morbidities associated with the ACEs (especially the increased risk of suicidality and self-harm) and of the requirements of their mandated reporting status that may arise from assessing trauma history. Being prepared to offer (or offer referrals to) empirically supported trauma-informed treatments (i.e., Trauma-focused CBT, EMDR, or possibly exposure therapy) is also advisable. In the end, the great depth and breadth of research done on the ACEs and associated outcomes present clinicians with a major set of resources that are most accessible if the clinician conducts a screening using the ACEs questionnaire. There are six common core elements of a trauma-informed approach: (1) build trauma-informed knowledge and skills; (2) establish safe and supportive relationships and environments; (3) provide trauma-informed assessment and treatment services; (4) involve youth and families; (5) promote trauma-informed procedures and policies; and (6) collaborate across sectors. There is a growing consensus among health care providers that a TIC frame provides an effective strategy for addressing ACEs. Trauma-Informed services regardless of contexts must be based on principles, policies, and procedures that provide safety, voice and choice. They must focus first and foremost on an individual’s physical and psychological safety, including responding appropriately to suicidality. They must also be flexible, individualized, and culturally competent, promote respect and dignity, hope and optimism and reflect best practice. Recent research indicates that the most effective approaches for supporting recovery from trauma are well-integrated psychological/ therapeutic health services that also reflect the centrality of trauma in the lives and experiences of consumers. Creating a trauma-informed system of care requires cross-system collaboration around information collection and sharing, training, a common vision across public and private systems, and the ability to blend funding in a way that creates a seamless system. It also requires leadership. A TIC approach typically integrates behavioral health specialists into the primary care environment. A TIC approach recognizes the vast consequences of trauma in the developing years and throughout a person’s lifespan. A trauma-informed practitioner will be better equipped to understand why their patients’ current state of health is not based on their addiction, maladaptive behavior, or mental illness as much as it is a consequence of the body’s physiologic and psychologic response to toxic stress in the developing years.

LIMITATIONS » There is a dearth of research on the need for teaching medical students about ACEs. » There is no research literature on the impact of using a TIC approach to address ACEs among vulnerable populations.

RECOMMENDATIONS The connection between trauma, health, mental health and co-occurring disorders such as substance abuse, eating disorders, HIV/ AIDS and further violence has been well-documented. In recent years many recommendations and guidelines have been created documenting the need for culturally-competent, trauma-informed care. These guidelines typically emphasize the need for holistic treatment in which all components of an individual’s history and identity are considered in treatment planning and service provision. Central elements of history and identity include exposure to traumatic incidents as well as sexual orientation and gender identity, experiences with homelessness and addiction. These factors shape the way people think, feel, relate to others and manage stress. Failure to consider these factors can lead to misdiagnosis, poor treatment outcomes and ineffective therapeutic relationships. Creating programs that are trauma-informed and culturally competent requires deliberate planning, training and organizational change at all levels including direct care staff, managers, directors, administration and boards of directors. Organizations that fail to engage in a thorough internal assessment of their competencies in these areas risk alienating the community. By failing to accommodate all aspects of clients’ identity, organizations can unknowingly create organizational structures, processes, cultures and/ or staff members that do not demonstrate inclusion or that are dismissive to vulnerable populations experiencing trauma.

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REFERENCES 1. Bernstein R. Treating Complex Traumatic Stress Disorders in Children and Adolescents: Scientific Foundations and Therapeutic Models , edited by J. D. Ford and C. A. Courtois. Vol 152014. 2. Fallot R, Harris M. Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol Community Connections; Washington, D.C. 2019. 3. Strait J, Bolman T. Consideration of Personal Adverse Childhood Experiences during Implementation of TraumaInformed Care Curriculum in Graduate Health Programs. Perm J. 2017;21. 4. Scheer JR, Poteat VP. Trauma-Informed Care and Health Among LGBTQ Intimate Partner Violence Survivors. Journal of Interpersonal Violence. 2018:0886260518820688. 5. (US) CfSAT. Trauma-Informed Care in Behavioral Health Services. . In: (US) SAaMHSA, ed. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2014. 6. Bateman J, Henderson C Trauma-Informed Care and Practice: towards a cultural shift in policy reform across mental health and human services in Australia: a national straegic direction2013. 7. Layne CM, Ippen CG, Strand V, et al. The Core Curriculum on Childhood Trauma: A tool for training a trauma-informed workforce. Psychological Trauma: Theory, Research, Practice, and Policy. 2011;3(3):243-252. 8. Kezelman C SP. The Last Frontier’ PRACTICE GUIDELINES FOR TREATMENT OF COMPLEX TRAUMA AND TRAUMA INFORMED CARE AND SERVICE DELIVERY2012. Located at: Adults Surviving Child Abuse, Australia. 9. Green BL, Saunders PA, Power E, et al. Trauma-Informed Medical Care: A CME Communication Training for Primary Care Providers. Family medicine. 2015;47(1):7-14. 10. Bassuk E. Guidance for Primary Care Clinicians. In: council HCftH, ed. Trauma and Homelessness. Nashville, TN: Health Care for the Homeless Council; 1999.

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11. van den Heuvel M, Martimianakis MAT, Levy R, Atkinson A, Ford-Jones E, Shouldice M. Social pediatrics: weaving horizontal and vertical threads through pediatric residency. BMC Medical Education. 2017;17(1):12. 12. Bethell CD, Carle A, Hudziak J, et al. Methods to Assess Adverse Childhood Experiences of Children and Families: Toward Approaches to Promote Child Well-being in Policy and Practice. Acad Pediatr. 2017;17(7s):S51-s69. 13. Goldstein E, Murray-García J, Sciolla AF, Topitzes J. Medical Students’ Perspectives on Trauma-Informed Care Training. The Permanente Journal. 2018;22:17-126. 14. Increasing awareness of Adverse Childhood Experience (ACE) and the benefits of inquiring about ACE. Family Medicine Block Clerkship, Student Projects 2014. 15. Pardee M, Kuzma E, Dahlem Chin Hwa Y, Boucher N, Darling‐Fisher Cynthia S. Current state of screening high‐ACE youth and emerging adults in primary care. Journal of the American Association of Nurse Practitioners. 2017;29(12):716724. 16. Tavakkoli M, Ann Cohen M, Alfonso C, M Batista S, TiamsonKassab M, Meyer P. Caring for Persons with Early Childhood Trauma, PTSD, and HIV: a Curriculum for Clinicians. Vol 382014. 17. Magen E, DeLisser HM. Best Practices in Relational Skills Training for Medical Trainees and Providers: An Essential Element of Addressing Adverse Childhood Experiences and Promoting Resilience. Acad Pediatr. 2017;17(7s):S102-s107. 18. Tink W, Tink JC, Turin TC, Kelly M. Adverse Childhood Experiences: Survey of Resident Practice, Knowledge, and Attitude. Fam Med. 2017;49(1):7-13. 19. K. Hopper E, Bassuk E, Olivet J. Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings~!2009-08-20~!2009-09-28~!2010-03-22~! Vol 32010. 20. Prevention NRCfMHPaYV. Adopting a Trauma-Informed Approach for LGBTQ Youth. In: Administration SAaMHS, ed.

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THE PRE- AND POST-CURRICULUM SURVEY » How familiar are you with the clinical and scientific findings of the Adverse Childhood Experiences (ACEs) Study? Unfamiliar / Somewhat Familiar / Extremely Familiar » How familiar are you with Trauma-Informed Care? Unfamiliar / Somewhat Familiar / Extremely Familiar » How comfortable are you discussing with your patient their personal history of physical, emotional, and sexual abuse? Uncomfortable / Somewhat Comfortable / Extremely Comfortable » How important do you think it is for a patient’s medical record to include any history of physical, emotional, and sexual abuse? Not important / Somewhat Important / Extremely Important » How likely will you be to administer and assess an ACEs questionnaire on your patients? Unlikely / Somewhat Likely / Extremely Likely / Uncertain what this is » How confident are you in knowing what to do to help your patient after discussing his/her history of trauma? Not Confident / Somewhat Confident / Extremely Confident

» Have you completed an ACEs questionnaire in the past? No / Yes » If no, how likely are you to complete an ACEs questionnaire on yourself? Unlikely / Somewhat Likely / Extremely Likely / Uncertain what this is » If no, how comfortable are you completing an ACEs questionnaire on yourself? Unlikely / Somewhat Likely / Extremely Likely / Uncertain what this is » If yes, how likely are you to discuss your personal results of the questionnaire with your own physician? Unlikely / Somewhat Likely / Extremely Likely » If yes, how comfortable are you discussing the results of the questionnaire with your own physician? Uncomfortable / Somewhat Comfortable / Extremely Comfortable » What is your sex? Male / Female

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YEAR 2 POLICY BRIEF

Teaching Medical Students to address Interpersonal Violence across the Life Course Conducted by: Paul D. Juarez, Michael Paul, Aramandla Ramesh, & Patricia Matthews-Juarez, PhD

EXECUTIVE SUMMARY BACKGROUND Interpersonal Violence (IV) encompasses a wide range of incidents from child abuse, youth violence, intimate partner violence, sexual violence, elder abuse, and gun violence, all of which are commonly encountered within the health care system. Vulnerable populations such as LGBTQ persons, migrant farm workers, and persons experiencing homelessness are at increased risk for IV. Approximately 63% of homeless women have experienced domestic violence in their adult lives, across the life course. After reviewing the title and abstract for 564 references, we conclude that Migrant and seasonal farm working women report higher rates of intimate partner violence (IPV) as compared to the national average, yet are often reluctant to report these experiences. Exposure to IV during childhood, adolescence, and adulthood has been found to be associated with low self-rated health, depression, alcohol addiction, obesity, increased risks for cancer, osteoarthritis, chronic conditions, acute myocardial infarction, musculoskeletal pain, headache, stomach problems, allergy, anxiety, sleeping problems, stress and suicidal thoughts. Despite recommendations from the AAMC, the CDC, and the WHO, there is a lack of consistency in how medical schools teach students about IV. IV education needs to be incorporated throughout the medical school curriculum and across clinical rotations to stress the prevalence of injury and the necessity to incorporate injury prevention and control into patient education.

METHODS A systematic review of seven databases was conducted to identify studies that focused on how medical schools are training students to address interpersonal violence (IV) across the life course. After reviewing seven databases, 1067 references were found. These references were downloaded and entered into the citation manager. After duplicates were removed, 556 references remained. Since we were primarily concerned with journal articles, we removed books (n=90), conference proceedings (n=43), book sections (n=30), and generic/serial citations (n=4), leaving us with 389 articles to review. After reviewing the titles and abstracts, we narrowed the search down to 13 articles which met our study criteria to conduct full article reviews.

RESULTS Findings of the systematic review revealed that lack of knowledge about IV among medical students is a significant deficit. Some medical student surveys demonstrated that an increase in training on IV led to an increase in IV-related knowledge. Other studies found that physicians who received training during their student life are more likely to screen for IV when they are in practice. Results from a systematic review of 28 (of 576) studies on intimate partner violence (IPV) among U.S. men who have sex with men (MSM) indicate that all forms of IPV occur among MSM at rates similar to or higher than those documented among women. » IV encompasses a wide range of incidents from child abuse, youth violence, intimate partner violence, sexual violence, elder abuse, and gun violence, all of which are encountered commonly within the health care system. » Vulnerable populations such as LGBTQ persons, migrant farm workers, and persons experiencing homelessness are at increased risk of IV. » Exposure to IV during childhood, adolescence, and adulthood has been found to be associated with low self-rated health,2 depression,3,4 alcohol addiction and obesity,5 increased risks for cancer,6 osteoarthritis,7 chronic conditions,8 acute myocardial infarction,9 musculoskeletal pain, headache, stomach problems, allergy, anxiety, sleeping problems, stress and suicidal thoughts.10–13 » IV is seldom a random, uncontrollable event, but rather its predictable and preventable2. » Injury-related morbidity and mortality disproportionately impact persons who are socially vulnerable due to age, race, gender, sexual identity, income, education, occupation, housing status, social support, disability, and place of residence. » Despite recommendations from the AAMC, the CDC, and the WHO, there is a lack of consistency in how medical schools teach students about IV. » Medical students typically are taught to screen for categorical types of IV, including child abuse, intimate partner violence, sexual assault/rape, and elder abuse without understanding the commonalities between them

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RECOMMENDATIONS Vulnerable populations are both at higher risk for IV and less likely to report violence victimization history due to fear, stigma, and lack of awareness that the physician may be able to help them. Physicians and other health-care workers are not being trained to include screening for risk of IV or to adopt routine standards of care for victims of violence. Curriculum change is one of many strategies and initiatives that must be implemented if we are to deal with the burden of IV. A trauma informed system of care provides an optimal setting for training medical students to be educated on IV prevention, screening, and treatment.

BACKGROUND Interpersonal violence (IV), also referred to as intentional injury, is “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, stunted emotional development, or deprivation1”. IV occurs across the life course and threatens the health and happiness of thousands of persons each year in the United States. IV encompasses a wide range of incidents from child abuse and neglect by caregivers, to youth violence (violence by adolescents and young adults aged 10 to 29 years that includes bullying, dating violence, cyber violence, gang violence, etc.), intimate partner violence, sexual violence, elder abuse, and gun violence. Intentional and unintentional injuries are the leading cause of death for Americans ages 1 to 44, and a leading cause of disability for all ages, regardless of sex, race/ethnicity, or socioeconomic status3. More than 180,000 people die from injuries each year, and approximately 1 in 10 sustains a nonfatal injury serious enough to be treated in a hospital emergency department. In 2010, 55,000 deaths United States were violence-related and 2.3 million people were treated for an assault or act of self-harm. » » » »

In 2015, roughly 683,000 cases of neglect and abuse were reported to child protective services. A total of 199,752 deaths from poisoning, motor vehicle and firearms were recorded in 2014. Homicide is the fourth leading cause of death (National Center for Health Statistics, 2016). Nearly 30 percent of women and 10 percent of men experience some form of intimate partner violence in their lifetime — physical violence, sexual violence, stalking and psychological aggression. » In 2008, one in every 10 elders reported instances of abuse within the last year. Beyond these injuries, millions of Americans every year are victims of child abuse, intimate partner violence, sexual violence, and elder abuse that do not result in medical attention.4 The effects of IV also extend beyond the acute injury and can have lasting physical, mental, sexual, and reproductive health consequences across the life course and result in substantial health burdens and costs4.

LGBTQ PERSONS While IPV among partners of the opposite sex has received much attention, IPV among same-sex partners has been neglected. Statistics compiled by the National Intimate Partner and Sexual Violence Survey (NISVS), found that lesbian women and gay men reported levels of IPV and sexual violence equal to or higher than those of heterosexuals.5 Results from a systematic review of 28 (of 576) studies on intimate partner violence (IPV) among U.S. men who have sex with men (MSM) indicate that all forms of IPV occur among MSM at rates similar to or higher than those documented among women.6 Findings from the CDC’s National Intimate Partner Violence and Sexual Violence (NISVS) show that among sexual minority women, bisexual women are 2-6 times more likely to report IPV compared to heterosexual women. The prevalence of IV and sexual abuse has risen considerably over the past decade and may be as high as or higher than the straight/general population.7 LGBTQ youth have also been found to be at equal or greater risk for IPV than their heterosexual counterparts. Overall, the prevalence of dating violence among LGBTQ adolescents is similar to that of heterosexuals. However, compared with heterosexuals and controlling for age, bisexual males had greater odds of reporting any type of abuse, and bisexual females had greater odds of experiencing sexual abuse. Controlling for age, lesbians had greater odds of being scared about their safety compared to heterosexual females, and bisexuals were more likely to be threatened compared to gay males/lesbians. Physicians can play a vital role in preventing and identifying IV, by screening, providing counseling to youth and their parents, and advocating for programs and policies that address LGBTQ bullying.8

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PERSONS EXPERIENCING HOMELESSNESS Homelessness has been identified as both a cause, an outcome, and a mediating factor associated with IV. Approximately 63% of homeless women have experienced domestic violence in their adult lives (National Network to End Domestic Violence). The causes of IV among women who are homeless are complex. Advanced medical problems and psychiatric illnesses, exacerbated by drug and alcohol abuse, in combination with the economic and social issues (such as the lack of housing and proper transportation) make this subset of the population a unique challenge for health care providers, local communities, and the government. Insufficient personal income, mental illness, addiction, and a lack of affordable housing are among the major reasons for homelessness among women and risk factors that increase their risk of IV. Homeless children and runaway youth often have high rates of past abuse also, with up to two-thirds of youth who are homeless reporting a history of physical or sexual childhood abuse.9-11 The experience of homelessness among children and youth appears to have numerous adverse implications and effects on their mental and physical health, neurocognitive development, and academic performance. A history of prior abuse has been found to contribute to increases in risky and impulsive behavior12 leading to subsequent, adverse, medical and mental health conditions.13 Homeless youth demonstrate increased rates of tobacco use, substance abuse, high-risk sexual behavior, victimization, and mental illness compared to their housed peers.9,11,14-18 In serving children and youth who are homeless and who have been victims of abuse and/or violence, health care providers need to understand (1) how childhood trauma may play a role in the genesis of their behavior, (2) how childhood trauma interacts with victimization on the streets to create vulnerability to psychopathology, and (3) the state of the current literature of trauma-informed interventions for children and youth.19

MIGRANT FARM WORKERS Migrant farm workers and their children are at increased risk for all types of IV, including child abuse, bullying, IPV, and sexual violence. They face a high risk of domestic violence, sexual violence, and harassment in the work place. Migrant and seasonal farm working women report higher rates of IPV as compared to the national average,20 yet are often reluctant to report these experiences. While the exact prevalence of workplace sexual violence and harassment among farmworkers is difficult to determine due to the challenges of surveying a seasonal, migrant, and often undocumented population, the problem is severe. Victims often face systemic barriers— exacerbated by their status as migrant and as farmworkers, and often as unauthorized workers—to reporting these abuses and bringing perpetrators to justice.

STATEMENT OF THE PROBLEM Despite advances in recent years in personalized medicine, medical technology, and pharmacology, our vast, expensive, and complex medical education system has failed to produce a physician workforce prepared to address the underlying social determinants of health which contribute to health disparities among vulnerable populations in our communities21. The current physician workforce is too small, specialized, and unprepared to work in inter-professional teams, ill-equipped to manage chronic diseases and injury, and lack the knowledge and skills needed to robustly promote IV prevention and control22. Interpersonal violence (IV) is an extremely complex phenomenon arising from the interaction of biological, social, cultural, economic and political factors2. The World Report on Violence and Health recommended the application of an ecological model to address the multifaceted nature of violence. An ecological model categorizes factors that increase the likelihood of IV into four levels: individual, relations, community, and societal. Physician involvement at each of these levels (screening, anticipatory guidance, patient education, community involvement, research, advocacy, legislation) can reduce IV. It is important that medical students understand and are prepared to take steps to address underlying individual, interpersonal, community and societal-level factors that increase the risk for IV among vulnerable populations. Intentional injury prevention efforts are typically classified on the basis of the at-risk group. Universal or primary interventions target a broad population without consideration of individual risk. Selective or secondary interventions are aimed at those who are considered to incur a higher risk of injury or violence, while indicated or tertiary interventions are directed at those who have demonstrated risky behavior. In 1993, the Centers for Disease Control and Prevention recommended that a national injury prevention and control training plan be required curricula of medical schools and be developed to encourage education about injuries and injury prevention. The American College of Emergency Physicians, the American College of Surgeons, and the Association of American Medical Colleges (AAMC), similarly, have called for the concepts of injury prevention and control to be part of undergraduate and resident medical education.23 However, current undergraduate medical school curricula continues to lack content and consistency in providing students training in IV.

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There is a limited evidence regarding best strategies for teaching medical students how to screen for and address the needs of vulnerable populations at risk of or affected by IV. The overall aim of this policy brief is to describe the need to incorporate IV into the medical school curriculum to teach future physicians the knowledge, awareness, and skills needed to screen for and respond to IV over the life course.

METHODS PROCEDURES A systematic review of seven databases was conducted to identify studies that focused on how medical schools are training students to address interpersonal violence (IV) across the life course. The databases that were searched included: PubMed, ERIC, SCOPUS, Web of Science, OVID, CINAHL, and Psych INFO. After searching the seven databases, 1067 references were found. These references were downloaded and entered into the citation manager, EndNote. In EndNote, we removed the exact and close duplicates (n=511), 556 references remained. Since we were primarily concerned with journal articles, we removed books (n=90), conference proceedings (n=43), book sections (n=30), and generic/serial citations (n=4). This left us with 389 articles to review. After reviewing the titles and abstracts of the 564 references, we narrowed the search down to 13 which met our study criteria to conduct full article reviews.

RESULTS/KEY FINDINGS Findings of the systematic review revealed that lack of knowledge of IV among students is a significant deficit24. A survey of 200 medical students and residents showed that their level of training on IV was inadequate and both groups expressed a desire to receive additional training25. Another survey of 2,316 medical students showed that only one fifth of medical students received extensive training on IV26. Student surveys revealed an improvement in their knowledge of domestic violence awareness after undergoing three hours of instruction27. Likewise, participation in an intensive domestic violence clerkship found improvements in the knowledge, attitudes, and skills of medical students28. A survey of medical students and residents revealed that compared to residents, medical students lacked knowledge about how to respond to IV29. Some surveys conducted among medical students have demonstrated that an increase in training on IV led to an increase in IV-related knowledge30. Other studies found that physicians who received training during their student life are more likely to screen for IV when they are in practice26. Medical schools that are affiliated with a hospital that has a trauma center are more likely to include IV education. These medical schools often introduce IV into the curriculum around child abuse, elder abuse, sexual assault and IPV. Some have used standardized patients while others have introduced personnel from community IV prevention and control resources, such as shelter staff, legal and law enforcement personnel31. One study, which employed standardized patients to teach medical students about IV, found improvements in comfort level and physician-patient communication32. Didactic based training of medical students in IPV prevention in a community based program was found to significantly improve students’ knowledge33. Efforts to assess the content of medical school curriculum in regard to family violence found differences of opinion between administrators and students about curricular offerings34. One survey found that over a fifth of medical students identified a positive history of family violence24. To be sensitive to this, it was recommended that curricular changes that address IV need to be sensitive to students’ personal experiences35. Similarly, addressing sexual violence in the medical school curricula may itself be traumatic for students who may have experienced sexual violence36,37. Both medical students and physician residents surveyed about incorporating sexual violence into the curriculum agreed that more research is needed to show that IV training actually increases knowledge, attitudes, skills of physicians, and patient outcomes38. Perceived barriers to physician screening for IV includes concerns expressed on time spent to evaluate patients and negative patient reactions39.

DISCUSSION Interpersonal violence is not an intractable social problem or an inevitable part of the human condition. Limited research findings clearly show that IV is a universal problem but that vulnerable populations, including LGBTQ, homeless persons, and migrant farm workers are at increased risk. Attributes that increase risk among vulnerable populations include a range of personal and social characteristics, such as race/ethnicity, age, gender, sexual orientation, religious affiliation, degree of acculturation; stigmatizing health conditions such as poor oral health, mental illness or physical disability; and indicators of social class, such as education, occupation, housing status, poverty, and legal barriers. Physicians provide care for acute injuries, mitigate further insult from sustained injuries, and provide information on primary and secondary injury prevention to patients. Yet studies have shown that health care providers do not always recognize or respond to issues of IV among vulnerable populations. Nearly all doctors will encounter persons who have been, or are at risk of being a victim of an intentional injury or treat someone in the aftermath of IV in their practice. There is a growing evidence base of the effectiveness of physician initiated interventions designed to prevent child abuse,40 intimate partner violence among adolescents,41 elder abuse,42 intimate partner violence among adults,43 youth violence,44 gun violence,45 and sexual violence.41

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As such, medical students, resident physicians, and other health care providers need to be trained to screen, prevent, intervene, and refer persons identified as at risk or engaged in IV. In clinical settings, injury prevention has not been fully integrated into practice and physicians are not as familiar with ways to prevent injuries as they are with those for other major killers such as heart disease, stroke, and cancer.46 Vulnerable populations are both at higher risk for IV and less likely to report violence victimization history due to fear, stigma, and lack of awareness that the physician may be able to help them. Physicians and other health-care workers are not being trained to include screening for IV risk or to adopt routine standards of care for victims of violence47. Curriculum change is one of many strategies and initiatives that must be implemented if we are to deal with the burden of injury. A trauma informed system of care provides an optimal setting for training medical students to carry out IV prevention, screening, and treatment Recommendations » IV education should be taught to medical students early on, as IV is a health issue that occurs across the life course to achieve better patient outcomes. » While designing curriculum, it is necessary to consider students preexisting attitudes, culture, and personal exposure to IV. » Medical students need to be prepared to take the necessary steps to address underlying individual, interpersonal, community and societal-level factors that increase the risk for IV among vulnerable populations. » IV education needs to be incorporated throughout the medical school curriculum and across clinical rotations to stress the prevalence of injury and necessity to incorporate injury prevention and control in patient education. » Physician involvement at each level of the ecological model (screening, anticipatory guidance, patient education, community involvement, and advocacy) can reduce IV. » IV education must occur within a trauma-informed system of care.

REFERENCES 1. Krug E, Dahlberg, LL, Mercy, JA, Zwi, AB and Lozano, R. World report on violence and health. Geneva2002. 2. Prevention CfDC. Healthy People 2010. 2006. 3. Welch V, Petkovic J, Pardo JP, Rader T, Tugwell P. Interactive social media interventions to promote health equity: an overview of reviews. Health Promotion and Chronic Disease Prevention in Canada : Research, Policy and Practice. 2016;36(4):63-75. 4. Houry D, Baldwin G. Announcing the CDC guideline for prescribing opioids for chronic pain. Journal of Safety Research. 2016;57:83-84. 5. Walters ML, Chen J., & Breiding, M.J. The National Intimate Partner and Sexual Violence Survey 2010 Findings on Victimization by Sexual Orientation National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention 2013. 6. Finneran C, Stephenson R. Intimate Partner Violence Among Men Who Have Sex With Men. Trauma, Violence, & Abuse. 2012;14(2):168-185. 7. Edwards KM. Intimate Partner Violence and the Rural– Urban–Suburban Divide. Trauma, Violence, & Abuse. 2014;16(3):359-373.

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8. Earnshaw VA, Bogart LM, Poteat VP, Reisner SL, Schuster MA. Bullying Among Lesbian, Gay, Bisexual, and Transgender Youth. Pediatric Clinics of North America. 2016;63(6):9991010. 9. Busen NH, Engebretson, Joan C. Facilitating risk reduction among homeless and street-involved youth. Journal of the American Academy of Nurse Practitioners. 2008;20(11). 10. Molnar BE, Shade SB, Kral AH, Booth RE, Watters JK. Suicidal behavior and sexual/physical abuse among street youth. Child Abuse & Neglect. 1998;22(3):213-222. 11. Kimberly D. Ryan RPK, Ana Mari Cauce, Haruko Watanabe, Danny R. Hoyt. Psychological consequences of child maltreatment in homeless adolescents: Untangling the unique effects of maltreatment and family environment. Child Abuse and Neglect,. 2000;24(3):333-352. 12. Nelson EC, Heath AC, Madden PF, et al. Association between self-reported childhood sexual abuse and adverse psychosocial outcomes: Results from a twin study. Archives of General Psychiatry. 2002;59(2):139-145. 13. Whitbeck LB, Hoyt, DR, Yoder, KA, Cauce, AM, Paradise, M. . Deviant Behavior and Victimization Among Homeless and Runaway Adolescents. 2001.

5th Annual Communities of Practice Conference 14. Chen X, Thrane L, Whitbeck LB, Johnson KD, Hoyt DR. Onset of Conduct Disorder, Use of Delinquent Subsistence Strategies, and Street Victimization among Homeless and Runaway Adolescents in the Midwest. Journal of interpersonal violence. 2007;22(9):1156-1183. 15. Kipke MD, Simon TR, Montgomery SB, Unger JB, Iversen EF. Homeless youth and their exposure to and involvement in violence while living on the streets. Journal of Adolescent Health. 1997;20(5):360-367. 16. Abma JC, Martinez GM, Copen CE. Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, National Survey of Family Growth 2006–2008. In: Statistics NCfH, ed. Vital Health Stat. Vol 232010:1-42. 17. Tyler KA, Whitbeck LB, Hoyt DR, Cauce AM. Risk Factors for Sexual Victimization Among Male and Female Homeless and Runaway Youth. Journal of Interpersonal Violence. 2004;19(5):503-520. 18. Suzanne Zerger AJS, Adi V. Gundlapalli. Homeless young adults and behavioral health: An overview. American Behavioral Scientist. 2008;51(6):824-841. 19. Davies BR, Allen NB. Trauma and homelessness in youth: Psychopathology and intervention. Clinical Psychology Review. 2017;54:17-28. 20. Meng G. The Vulnerability of Immigrant Farmworkers in the US to Sexual Violence and Sexual Harassment. 2012; https://www.hrw.org/report/2012/05/15/cultivating-fear/ vulnerability-immigrant-farmworkers-us-sexual-violenceand-sexual. 21. Satterfield JM C, PA, ed Aligning Medical Education with the Nation’s Health Priorities. Rockville MD: Agency for Healthcare Research and Quality and Office of Behavioral and Social Sciences Research, National Institutes of Health;; 2015. Kaplan R SM, David D (Eds), ed. Population Health: Behavioral and Social Science Insights. 22. Kaplan R SM, David D (Eds). ed Population Health: Behavioral and Social Science Insights. Rockville: AHRQ and Office of Behavioral and Social Sciences Research/NIH 2015. 23. injury AoAMCTfpa. Report of the Advisory Panel on Injury Prevention and Control Education for Medical Students. 2005. 24. Cullinane PM1 AE, Freund KM. First-year medical students’ knowledge of, attitudes toward, and personal histories of family violence. Acad Med. 1997;72(1):48-50. 25. Sprague S KR, Madden K, Sosanjh S, Mathews DJ, Bhandari M. Perceptions of Intimate Partner Violence: a cross sectional survey of surgical residents and medical students. J Inj Violence Res. 2011. 26. Frank E EL, Saltzman LE, Houry D, McMahon P, Doyle J. Clinical and personal intimate partner violence training experiences of U.S. medical students. J Womens Health. 2006;15(9):1071-1079. 27. Ernst AA, Houry D, Nick TG, Weiss SJ. Domestic Violence

Year 2 Research Projects Awareness and Prevalence in a First-year Medical School Class*. Academic Emergency Medicine. 1998;5(1):64-68. 28. Jonassen JA, Pugnaire MP, Mazor K, et al. The effect of a domestic violence interclerkship on the knowledge, attitudes, and skills of third-year medical students. Academic medicine : journal of the Association of American Medical Colleges. 1999;74(7):821-828. 29. Carlson M, Kamimura A, Al-Obaydi S, Trinh HN, Franchek-Roa K. Background and Clinical Knowledge of Intimate Partner Violence: A Study of Primary Care Residents and Medical Students at a United States Medical School. Health equity. 2017;1(1):77-82. 30. Buranosky R, Hess R, McNeil MA, Aiken AM, Chang JC. Once Is Not Enough: Effective Strategies for Medical Student Education on Intimate Partner Violence. Violence Against Women. 2012;18(10):1192-1212. 31. Hill JR. Teaching About Family Violence: A Proposed Model Curriculum. Teaching and Learning in Medicine. 2005;17(2):169-178. 32. Heron SL, Hassani DM, Houry D, Quest T, Ander DS. Standardized Patients to Teach Medical Students about Intimate Partner Violence. The western journal of emergency medicine. 2010;11(5):500-505. 33. Moskovic CS, Guiton G, Chirra A, et al. Impact of participation in a community-based intimate partner violence prevention program on medical students: a multi-center study. Journal of general internal medicine. 2008;23(7):1043-1047. 34. Alpert EJ, Tonkin AE, Seeherman AM, Holtz HA. Family Violence Curricula in U.S. Medical Schools. American Journal of Preventive Medicine. 1998;14(4):273-282. 35. Gerber MR, Tan AKW. Lifetime intimate partner violence exposure, attitudes and comfort among Canadian health professions students. BMC research notes. 2009;2:191-191. 36. Kennedy KM VA, Bonner N, Stewart B, McGrath D. How teaching on the care of the victim of sexual violence alters undergraduate medical students’ awareness of the key issues involved in patient care and their attitudes to such patients J Forensic and Legal Med. 2013;20(6):582-587. 37. Kennedy K. The case in favour of educating medical students about sexual violence. Medical Teacher. 2014;36(3):267-268. 38. Hamberger LK. Preparing the Next Generation of Physicians: Medical School and Residency-Based Intimate Partner Violence Curriculum and Evaluation. Trauma, Violence, & Abuse. 2007;8(2):214-225. 39. Aluko OE, Beck KH, Howard DE. Medical Students’ Beliefs About Screening for Intimate Partner Violence: A Qualitative Study. Health Promotion Practice. 2015;16(4):540-549. 40. Jack SM, Catherine N, Gonzalez A, MacMillan HL, Sheehan D, Waddell C. Adapting, piloting and evaluating complex public health interventions: lessons learned from the Nurse–

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Year 2 Research Projects Family Partnership in Canadian public health settings. Health Promotion and Chronic Disease Prevention in Canada : Research, Policy and Practice. 2015;35(8-9):151-159. 41. Lundgren R, Amin A. Addressing Intimate Partner Violence and Sexual Violence Among Adolescents: Emerging Evidence of Effectiveness. Journal of Adolescent Health. 2015;56(1):S42-S50. 42. Ayalon L, Lev S, Green O, Nevo U. A systematic review and meta-analysis of interventions designed to prevent or stop elder maltreatment. Age and Ageing. 2016;45(2):216-227. 43. Bourey C, Williams W, Bernstein EE, Stephenson R. Systematic review of structural interventions for intimate partner violence in low- and middle-income countries: organizing evidence for prevention. BMC Public Health. 2015;15:1165.

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5th Annual Communities of Practice Conference 44. Matjasko JL, Vivolo-Kantor AM, Massetti GM, Holland KM, Holt MK, Dela Cruz J. A systematic meta-review of evaluations of youth violence prevention programs: Common and divergent findings from 25 years of metaanalyses and systematic reviews. Aggression and Violent Behavior. 2012;17(6):540-552. 45. Gjertsen F, Leenaars A, Vollrath ME. Mixed Impact of Firearms Restrictions on Fatal Firearm Injuries in Males: A National Observational Study. International Journal of Environmental Research and Public Health. 2014;11(1):487-506. 46. R I. Injury prevention and lifestyle medicine. Am J Lifestyle Med. 2010:4-5. 47. Haegerich TM, Dahlberg LL, Simon TR, et al. Prevention of injury and violence in the USA. Lancet (London, England). 2014;384(9937):64-74.

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YEAR 3 PROJECT SUMMARY

Sexual Violence among Vulnerable Populations Principal Investigator: Patricia Matthews-Juarez, Ph,D., Email: pmatthews-juarez@mmc.edu Phone: (615) 327-6526 Contact person: Paul D. Juarez, Ph.D., Email: pjuarez@mmc.edu, Phone: (615) 327-6992 Date funded: UH1HP30348/ 07/01/2016 – 06/30/2021 Co-Investigators: Aramandla Ramesh, Ph.D., Matthew Morris, Ph.D., R. Lyle Cooper, Ph.D., MSSW, Mohammad Tabatabai, Ph.D., Thomas A. Arcury, Ph.D, Beth Shinn, Ph.D., and Leandro Mena, M.D.

PROJECT DESCRIPTION: The aim of this research is to identify and assess the extent to which medical schools prepares students to address sexual violence among vulnerable populations. We propose to answer several research questions through a systematic review of the literature, and to conduct surveys of both patients and providers in six community health centers affiliated with our national partners (Fenway Institute, Migrant Farmworkers Clinician Network, and National Healthcare Council for the Homeless) We will disseminate findings through scholarly presentations at graduate medical education conferences and meetings, peer reviewed publications and a policy brief and provide technical assistance to medical schools on how to address sexual violence among vulnerable populations in their curriculum.

STATEMENT OF THE PROBLEM Every 2 minutes, someone in the United States experiences a sexual assault. Sexual assault encompasses a number of acts ranging from inappropriate exposure or touching, to forced viewing of sexual encounters, to penetration. In addition to prevention, it’s important for health care providers to know who and when to screen for sexual assault, how to screen, and what to do for people who have experienced a sexual assault. Data show that the majority of completed and attempted sexual assaults against women are not reported to the police. In fact, most women who are victims of childhood or adult sexual violence are hesitant to speak to their families, friends or health care providers about it.

RESEARCH QUESTIONS OR HYPOTHESES: » What are vulnerable populations’ experiences and/or expectations of the health care system in addressing their history of sexual violence? » How are medical students being taught to address patient’s history of sexual violence? » What are key issues that need to be addressed by health care providers to ensure effective care for vulnerable populations who have experienced sexual violence? » How can the medical school curriculum be modified to ensure students can provide culturally appropriate care for vulnerable patients who have experienced sexual violence?

PROJECT GOALS: » To identify the needs of patients who have experienced sexual violence, with an emphasis on vulnerable populations, and how health care providers can best address them. » To identify provider experiences and perceptions and/or barriers to addressing sexual violence among clinic patients. » To identify and/or develop model curricular elements that can be used by medical schools to prepare students to effectively address sexual violence among vulnerable populations. » To disseminate research results and curricular modules to graduate medical education audiences on effective ways to teach medical students to address sexual violence in vulnerable populations.

GEOGRAPHIC COVERAGE: Our research will be national in scope, covering the entire United States.

RESEARCH DESCRIPTION TITLE: Sexual Violence among Vulnerable Populations

STATEMENT OF THE PROBLEM Sexual violence is a common experience in the lives of both men and women1. No one is immune: it crosses all socioeconomic, racial, gender, and cultural boundaries. Current estimates suggest that one in six women and one in 33 men will experience attempted or completed rape (i.e., forced oral, anal, or vaginal penetration) in his or her lifetime2 One out of every 6 American women has been the victim of an attempted or completed rape in her lifetime (14.8% completed, 2.8% attempted). About 3% of American men—or 1 in 33—have experienced an attempted or completed rape in their lifetime.2 In addition, Child Protective Services agencies substantiated, or found strong evidence to indicate that, 63,000 children a year, a majority of whom were between 12 and 17 years of age, were victims of sexual abuse3. Among victims under the age

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of 18, 34% were under the age of 12, while 66% of victims of sexual assault and rape were age 12-17 years of age3. Given the high rates of sexual violence and potential health impacts, it is therefore likely that most health care providers will come into contact with victims of sexual violence. Sexual violence can have psychological, emotional, and physical effects on a survivor4. These effects aren’t always easy to deal with, but when diagnosed and with the right help and support they can be managed by the primary care team. People who have been sexually victimized have been found to be more likely to suffer from chronic physical and mental health problems than those who have not been victimized, and believe that their health is fair or poor5. Other physical consequences of sexual violence include unintended pregnancy, chronic pain, gastrointestinal disorders, gynecological complications, genital injuries, and sexually transmitted disease4. Psychological response to being a victim of sexual assault include depression, anxiety, stress and fear, making it difficult to adjust or cope for some time afterward6. Female survivors of sexual violence visit the doctor more often than women who have not been victimized.7 Having a non-abusive relationship with a healthcare provider fosters mutual trust and promotes long-term health success by allowing a survivor to feel taken care of in an adult relationship with his physician, based on that trust8. While studies have shown that most female patients want to be asked about their experiences with sexual violence by their health care providers9, few medical professionals screen any patients, female or male, for such trauma10. This may be due to a lack of training, time, or comfort on the part of the health care provider11. A qualitative study of physicians from five different specialties undertaken to identify barriers to providing care for women who are sexual violence survivors, identified several factors which hindered their ability to fulfill their roles. They include: (1) internal barriers (e.g. discomfort with the topic of sexual assault); (2) physician-patient communication; and (3) system obstacles (e.g. competing priorities for time)12. Vulnerable Populations and Sexual Violence. Marginalized populations are often the most vulnerable for sexual violence and often face the greatest obstacles to gaining protection and necessary services13. Factors such as race, class, ethnicity, gender, sexual identity and social conditions, such as sex workers, homelessness, and migrant farm work may make persons particularly vulnerable to sexual assault. Lesbian, Gay, Bisexual, Transgendered, Queer (LGBTQ) The lifetime prevalence of rape among LGBTQ persons by any perpetrator is high. Among LGBTQ women, rape prevalence was 13.1% for lesbians and 46.1% for bisexual women, as compared to 17.4% for heterosexual women. For men, rape prevalence for gay and bisexual men is too small to estimate; but for heterosexual men it was 0.7%14. It has been estimated that LGBTQ youth comprise 35% to 50% of all homeless youth in the United States. A systematic review of 75 studies undertaken to assess the level of sexual victimization among LGBTQ individuals showed significant rates of child, adult, intimate partner, and hate-related sexual assault, suggesting that individuals who identify themselves as LGBTQ face a higher risk for sexual violence than the general population.15 A survey conducted in the Los Angeles area found that 4% of single men were sexually assaulted while homeless compared to 16% of single women. LGBTQ persons face social stigma, discrimination, and often rejection by their families, which adds to the physical and mental strains/challenges that all homelessness persons must struggle with. Survivors of sexual assault also face significant challenges in overcoming their trauma, including diminished mental and physical health, lack of financial resources to access medical care, difficulties maintaining regular routines (including stable employment, housing and parenting) and a lack of familiarity with accessing resources and trusting service providers. Individuals who identify as LGBTQ and have a history of sexual assault victimization also have been found to be at increased risk for unprotected sex, mood disorders, and suicide attempts. LGBTQ youth also have been found to be at increased risk for experiencing barriers to post-trauma services due to homophobia and transphobia16. Persons Experiencing Homelessness. Homelessness dramatically increases women’s risk of sexual assault. Ninety-two percent of women experiencing homelessness report having experienced severe physical and/or sexual assault at some point in their lives with 60% of women experiencing homelessness report having been abused by the age of 12. Similarly, 61% of homeless girls and 16% of homeless boys reported having been sexually abused before leaving home17. Homeless women are more likely than housed women to suffer from substance abuse, mental illness, domestic violence, and severe physical health limitations that make self-defense in a dangerous situation more difficult. Women who were dependent on drugs or alcohol, were more likely to receive income from survival sex or panhandling for money which increased risk for being a victim of sexual violence. Women living on the streets do not have the same level of safety provided to those who are housed. A range of factors increase homeless women's risk of adult sexual victimization, including childhood abuse, substance dependence, length of time homeless, engaging in economic survival strategies, location while homeless, mental illness, and physical limitations. Homeless women, men and youth often are faced with making choices they normally would not, simply to have a roof overhead, or food and shelter for their children18. Homeless women are “particularly vulnerable to sexual violence at the hands of strangers, acquaintances, pimps, sex traffickers, and intimate partners on the street, in shelters, or in precarious housing situations19.

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When a person experiences homelessness, he or she is living in a dangerous environment where their basic needs such as shelter, food, and clothing, are no longer being met. Persons experiencing homelessness struggle with where to shower, brush their teeth, use the bathroom, and other hygiene processes that those of us who are housed often do not think about. To attend to all of one’s basic needs while also looking for the limited affordable housing and employment makes all of these decisions and tasks more stressful and overwhelming, and makes getting out of homelessness even more difficult for the individual or family20. Migrant Farm Workers. Women represent an estimated 630,000 farmworkers in the United States. The majority of these workers selfidentified as being Mexican (75%), with U.S. born workers constituting the second largest group of workers (23%). Some of these workers are migrant, meaning they travel from state to state and/or from city to city to perform their work. Other workers are seasonal, meaning they live in one state and perform temporary or seasonal work in locations near them. Some farmworkers are guestworkers; temporary employees brought on H-2A visas, who come to the United States for specified periods of time to conduct agricultural labor.21 Women who work as migrant workers face a significant risk of sexual violence and sexual harassment22. According to Human Rights Watch, hundreds of thousands of immigrant farmworker women and girls in the United States face a high risk of sexual violence and sexual harassment in their workplaces because US authorities and employers fail to protect them adequately22, Sexual violence and harassment in the agricultural workplace are fostered by a severe imbalance of power between employers and supervisors and their low-wage, immigrant workers. While the exact prevalence of workplace sexual violence and harassment among farmworkers is difficult to determine due to the challenges of surveying a seasonal, migrant, and often unauthorized population, the problem is serious. Migrant farmworkers who are victims of sexual violence often face systemic barriers to reporting these abuses, exacerbated by their status as farmworkers and often as undocumented workers. Migrant farmworkers, especially those who are undocumented, face added difficulties in seeking safety, medical help, and justice when victims of any type of violence. These difficulties include: language, economic, and cultural barriers; fear of deportation; fear of the police; and misinformation about the legal system. Most migrant farmworkers said they do not report incidents of sexual violence in the workplace, fearing reprisals. Health Care Providers. There are many reasons that physicians do not screen for sexual assault. They lack training, fear approaching sensitive subjects, lack time to screen, or do not have private facilities for screening. Most do not screen because they do not know how to ask questions and/or how to respond when the victim discloses. However, when properly screened, victims can disclose their abuse and receive the care and services they need. The "telling" alone often provides meaning to the patients experience and helps them to better manage their emotions. In contrast, not asking, reinforces the victims' silence. The National Sexual Violence Resource Center (NSVRC) recommends that screening should take place during routine wellness exams and during episodic illness exams when symptoms are suspicious for sexual assault. Red flags include: anxiety; depression; sudden-onset sleep disorders; stress-related complaints; requests for pregnancy testing, emergency contraception, or testing for sexually transmitted diseases; pelvic area trauma; and bruising that may be from restraints. The NSVRC cautions that clinicians should keep in mind that victims vary in response to sexual assault, ranging at one end to showing no response and at the other end to showing significant emotional or physical symptoms. To ensure that sexual assault is dealt with adequately, the NSVRC recommends clinicians develop a protocol to ensure that all patients are screened adequately and consistently. Protocols should ensure privacy in both the interview, which should take place when victims have their clothing on, and the documentation. Based on indirect evidence (feedback from women who were victims of sexual assault), the World Health Organization recommends a minimum set of actions and principles that should guide the health-care response to women suffering from sexual violence, whether by an intimate partner, relative, acquaintance or stranger, regardless of the circumstances23. The below recommendations are modified WHO recommendations which have been extend to men. Recommendations include: » » » » »

ensuring consultation is conducted in private ensuring confidentiality, while informing patients of the limits of confidentiality (e.g. when there is mandatory reporting) being non-judgmental and supportive and validating what the patient is saying providing practical care and support that responds to her/his concerns, but does not intrude asking about a history of sexual violence, listening carefully, without pressuring the patient to talk (care should be taken during sensitive topics when interpreters are involved) » helping the patient access information about resources, including legal and other services that she might think helpful » assisting the patient to increase safety for self and children, where needed and » Providing or mobilizing social support. If health-care providers are unable to provide first-line support, they should ensure that someone else (within their health-care setting or another that is easily accessible) is immediately available to do so.

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RESEARCH WORK PLAN RESEARCH STRATEGIES AND METHODOLOGY: 1. To identify the needs of patients who have experienced sexual violence, with an emphasis on vulnerable populations, and how health care providers can best address them. Methodology. Ten patients who have a history of sexual violence will be recruited by a staff member at one urban and one rural community health center affiliated with each of our three national partner organizations (Fenway Institute, Migrant Farmworkers Clinician Network, and National Healthcare Council for the Homeless). The survey instrument will be developed jointly by clinic and/or national partner staff and MMC staff and address history of sexual violence, health care services received, and recommendations on how services could be provided that better meet the needs of sexual violence survivors. The survey instrument will consist of approximately 20 questions and take about 15-20 minutes to complete. Participants will be provided an incentive to complete the survey. The survey will be submitted to the MMC IRB approval. 2. To identify provider experiences and perceptions and/or barriers to addressing sexual violence among clinic patients. Methodology. Ten health care staff will be recruited from an urban and rural clinic affiliated with each of the three national partner organizations to complete the survey. The survey instrument will be developed jointly by clinic and/or national partner staff and MMC staff and address clinic and provider experience and standards for addressing sexual violence. Health care providers will be asked to make recommendations on how service needs of sexual violence survivors could be better addressed. The survey instrument will consist of approximately 20 questions and take about 15-20 minutes to complete. Participants will be provided a $25 incentive to complete the survey. The survey will be submitted to the MMC IRB approval. 3. To identify and/or develop model curricular elements that can be used by medical schools to prepare students to effectively address sexual violence among vulnerable populations. Methodology. We will identify and maintain a repository of best practices in medical student education about screening and treatment for sexual violence among LGBTQ, homeless persons, and migrant workers. We will develop model medical education curricular modules on sexual violence, including a minimum of one patient simulation script. We will map recommended curricular units on interpersonal violence across the lifespan to the Medbiquitous Curriculum Inventory Working Group Standardized Instructional and Assessment Methods and Resource Types. The provision of high-quality multicultural victim assistance will acknowledgment of the cultural customs of recovery from traumatic events; supporting cultural paths to mental wellness and incorporating them into victim services and referrals; and multiethnic teamwork to implement and monitor effective victim services. 4. To disseminate research results and curricular modules to graduate medical education audiences on effective ways to teach students to address sexual violence. Methodology. We will identify and disseminate best practices in medical student education about screening and treatment for sexual violence among LGBTQ, homeless persons, and migrant workers through scholarly presentations and peer reviewed publications. We will identify and disseminate model curricular elements that can be used by other medical schools to prepare students to effectively address the needs of vulnerable populations exposed to sexual violence. We will disseminate a policy brief with recommendations about the role of medical schools in training students about the effects of sexual violence on vulnerable populations.

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REFERENCES 1. Tjaden P. T, N. Prevalence, incidence and consequences of violence against women: Findings from the National Violence Against Women Survey. In. U.S. Department of Justice, National Institute of Justice. WA DC: U.S. Department of Justice, National Institute of Justice; 2000. 2. Tjaden P1 TN, Allison CJ. Comparing violence over the life span in samples of same-sex and opposite-sex cohabitants. Violence Vict. 1999;14(4):13-25. 3. Crime TNCfVo. Child Sexual Abuse Statistics. 2018; http:// victimsofcrime.org/media/reporting-on-child-sexual-abuse/ child-sexual-abuse-statistics. Accessed 12/13, 2018. 4. Centers for Disease Control and Prevention. Sexual Violence: Consequences. Violence Prevention 2018; https://www.cdc. gov/violenceprevention/sexualviolence/consequences.html. Accessed 12/13, 2018. 5. Golding JM, Cooper ML, George LK. Sexual assault history and health perceptions: Seven general population studies. Health Psychology. 1997;16(5):417-425. 6. Center NSVR. Assessing Patients for Sexual Violence A Guide for Health Care Providers. Enola, PA, 2011. 7. Chivers-Wilson KA. Sexual assault and posttraumatic stress disorder: a review of the biological, psychological and sociological factors and treatments. McGill Journal of Medicine. An international forum for the advancement of medical sciences by students. 2006;9(2):111-118. 8. Spinelli F. The Sexually Abused Man’s Relationship with his Physician. J Clin Case Rep 2016;6:893. 9. Littleton HL, Breitkopf CR, Berenson AB. Correlates of anxiety symptoms during pregnancy and association with perinatal outcomes: a meta-analysis. American Journal of Obstetrics and Gynecology. 2007;196(5):424-432. 10. McAfee RE. Physicians and domestic violence: Can we make a difference? JAMA. 1995;273(22):1790-1791. 11. Stayton CD, Duncan DM. Mutable influences on intimate partner abuse screening in health care settings: a synthesis of the literature. Trauma Violence Abuse. 2005;6(4):271-285. 12. Amin P, Buranosky R, Chang JC. Physicians' Perceived Roles, as Well as Barriers, Toward Caring for Women Sex Assault Survivors. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2017;27(1):43-49.

13. The Advocates for Human Rights. Sexual Assault and Vulnerable Populations. Stop Violence Agaisnt Women 2018; http://www. stopvaw.org/sexual_assault_and_vulnerable_populations. Accessed 12/13, 2018. 14. Walters M, Chen J, Breiding, M. National Intimate Partner and Sexual Violence Survey 2010: Findings on Victimization by Sexual Orientation. 2011; https://ncvc.dspacedirect.org/ handle/20.500.11990/251. Accessed 12/13, 2018. 15. Rothman EF, Exner D, Baughman AL. The prevalence of sexual assault against people who identify as gay, lesbian, or bisexual in the United States: A systematic review. Trauma, Violence, & Abuse. 2011;12(2):55-66. 16. Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review. Cureus. 2017;9(4):e1184-e1184. 17. Estes RaW, N. The Commercial Sexual Exploitation of Children in the U.S., Canada, and Mexico. In. Philadelphia, PA: The University of Pennsylvania School of Social Work; 2001. 18. families Dfwa. The facts about sexual assault. 2018; https://www. doorwaysva.org/our-work/education-advocacy/the-facts-aboutsexual-assault/. Accessed 12/13, 2018. 19. Goodman L, Fels K, Glenn C. No Safe Place Sexual Assault in the lives of homeless women. In: Prevention CDC, ed: National online Resource Center of Violence against women; 2006. 20. Voice of Sexual Assault and Homelessness: A Vulnerable Population. 2016; https://www.ourvoicenc.org/blog/sexualassault-and-women-experiencing-homelessness-a-vulnerablepopulation/. Accessed 12/13, 2018. 21. Justice CAGJ. Facts About Workplace Sexual Violence Against Farmworker and Other-Low Wage Immigrant Women Farmworker Sexual Violence Facts 2018; https://cagj.org/foodjustice/food-justice-resources/farmworker-sexual-violence-facts/. Accessed 12/13, 2018. 22. Watch HR. Cultivating fear: the vulnerability of immigrant farm workers in the US to sexual violence and sexual harassment. Human Rights Watch Report, 2012. https://www.hrw.org/ report/2012/05/15/cultivating-fear/. Accessed 2/9/2017, 2017. 23. World Health Organization. Responding to Intimate Partner Violence and Sexual Violence Against Women: WHO Clinical and Policy Guidelines. In. Geneva: WHO; 2013.

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YEAR 3 PROJECT SUMMARY

Opioid Use Disorder in Vulnerable Populations Principal Investigator: Patricia Matthews-Juarez, PhD., Email: pmatthews-juarez@mmc.edu Phone: (615) 327-6526 Contact person: Paul D. Juarez, Ph.D., Email: pjuarez@mmc.edu, Phone: (615) 327-6992 Date funded: UH1HP30348/ 07/01/2016 – 06/30/2021 Co-Investigators: Aramandla Ramesh, Ph.D., Matthew Morris, Ph.D., R. Lyle Cooper, Ph.D., MSSW, M Mohammad Tabatabai, Ph.D., Thomas A. Arcury, PhD, Beth Shinn, Ph.D., and Leandro Mena, M.D.

PROJECT DESCRIPTION: The aims of this research are to: 1) conduct a systematic review of the literature of how medical schools are training students to respond to the opioid use disorder (OUD) epidemic; 2) conduct two focus groups from each vulnerable population, each comprised of 10-12 patients, to identify their expectations and experiences of the role of health care providers in responding to the opioid epidemic; 3) conduct surveys of health care providers to identify how they currently are responding to the OUD crisis; 4) use the Community of Practice (COP) annual meeting to translate patient and provider survey responses on opioids into core curricular elements; 5) disseminate recommendations to medical schools on how to best teach students about OUD and the needs of vulnerable populations; and 6) disseminate research findings to medical school faculty through scholarly presentations at conferences and meetings, peer reviewed publications and policy briefs on how to best address the needs of vulnerable populations about OUD.

STATEMENT OF THE PROBLEM. OUD has risen to a level of national crisis as the number of people abusing prescription and illicit drugs continues to spike. Certain populations have been hit harder by the opioid epidemic than others. Death rates are markedly higher among those who are most vulnerable, including persons with less than a college degree, regardless of age group or gender, and among populations that experience health disparities and mental illness, including LGBTQ persons, individuals experiencing homelessness, and migrant farm workers. Discrimination, implicit bias, lack of access to care, lack of a culturally competent workforce, and other psycho-social and socio-economic factors create unique challenges that both increase risk for opioid use and misuse and present barriers to treatment adherence among vulnerable populations. Addressing the opioid crisis so that all affected populations benefit will require a comprehensive approach that addresses pain management, overdose, addiction and recovery treatment, and relapse prevention, as well as targeting underlying psycho-social, economic, legal and policy factors which contribute to the crisis.

RESEARCH QUESTIONS OR HYPOTHESES: » What are patient expectations and experiences of the role of health care providers in OUD prevention, screening, treatment, referral, recovery, and relapse? » How do health care providers define their role in providing OUD services to vulnerable populations? » What are core elements of OUD to be included in medical education curriculum? » What curricular elements are needed to ensure medical students have the knowledge and skills needed to provide culturally appropriate OUD services for vulnerable populations?

PROJECT GOALS: » To identify experiences and expectations of vulnerable populations on the role of health care providers in screening, prevention, treatment, referral and relapse prevention for OUD? » To identify how health care providers define their roles in providing OUD services to vulnerable populations. » To identify and/or develop model curricular elements that can be used by medical schools to prepare students to effectively address the needs of vulnerable populations related to OUD. » To disseminate research results and curricular modules to graduate medical education audiences on effective ways to teach medical students to address OUD among vulnerable populations.

GEOGRAPHIC COVERAGE: Our research will be national in scope, covering the entire United States.

RESEARCH DESCRIPTION TITLE: Opioid Use Disorder in (LGBTq, Person Experiencing Homelessness, and Migrant Farm Workers

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STATEMENT OF THE PROBLEM Since 2000, the rate of opioid-related overdose deaths has more than tripled, from around 13,000 to over 49,000. In 2014, almost 2 million Americans abused or were dependent on prescription opioids and as many as 25% of people who receive prescription opioids for non-cancer pain in primary care settings struggle with addiction. While deaths from prescription opioid pain relievers appears to be plateauing nationally (from approximately 17,000 in 2011 to a little over 19,000 in 2016), the increase in the number of deaths from heroin (from around (4,000 in 2010 to about 16,000 in 2017) and synthetic opioids (predominantly fentanyl—from less than 5,000 in 2014 to over 29,000 in 20171), have exploded with no sign of abatement. In addition to opioid related deaths, in 2016 more than 366,000 people were treated in emergency departments for misusing prescription opioids – an over two-fold increase since 2005. While OUD has gained public consciousness in recent years, the impact of the opioid crisis on vulnerable and traditionally disenfranchised populations, such as those who identify as LGBTQ, persons experiencing homelessness, and migrant farmworkers is often less appreciated. Vulnerable subpopulations often experience unique challenges, such as lack of financial resources and insurance, stigma and discrimination, access to culturally competent health care, and fractured social support systems that affect their receptiveness and access to treatment and susceptibility to relapse. While the opioid epidemic continues to grow, little is known about how medical schools are preparing the future physician workforce to address the opioid crisis in general and the needs of vulnerable populations, in particular. A culturally competent workforce that is prepared to address the needs of all populations is critical to combatting the opioid epidemic There is an unmet need for a culturally competent workforce that is prepared to provide OUD prevention and treatment services across a wide range of populations. Current efforts to address the opioid crisis reveal both common and unique needs within and across communities, including those that are most vulnerable, such as persons who are LGBTQ, experiencing homelessness, and/or are migrant farmworkers. In addition to common risk factors, each vulnerable population brings a unique capacity for resiliency and recovery that can be leveraged to influence their engagement and successful completion of prevention and treatment interventions. To provide culturally congruent and competent prevention and treatment services, health care providers need to understand the influence of culture and context on substance abuse patterns; common co-morbidities; health knowledge, attitudes and help-seeking behaviors; and barriers to adherence. Understanding commonalities and differences among vulnerable populations is critical to designing and implementing effective OUD prevention and treatment curricula for medical students. Chronic pain is extremely common in adults experiencing homelessness and is a risk factor in opioid use disorder. Findings from surveys of this population show that 50-63% of adults in shelters reported chronic pain and only half said it was being treated. Among National Health Care for the Homeless Council (NHCHC) clinicians, only 23% believe they adequately manage pain. The NHCHC has issued chronic pain management guidelines to respond to this problem. There is strong evidence that medication assisted treatment can be effective and life-saving for individuals with opioid use disorder. Clinical practice guidelines indicate opioid agonist treatment (OAT) of buprenorphine and methadone as a first line measure. If this is not available or feasible, extended release injectable naltrexone is recommended. Access to OUD medications is increasing steadily due to rising demand. Prevention and treatment for substance use disorders can be best understood within a context in which the influences of gender, race and ethnicity, culture, education, age, geographic location, sexual orientation, social and economic determinants, and discrimination are considered. Common elements facing vulnerable populations often include trauma, stigma, and/or other psycho-social and socioeconomic stressors. Research suggests specific and culturally appropriate clinical, programmatic, and administrative strategies and resources required for OUD treatment and recovery are needed to address the needs of diverse and vulnerable populations.

VULNERABLE POPULATIONS: LGBTQ. LGBTQ persons are more likely than their straight counterparts to face social stressors associated with their sexual identity and behavior, including discriminatory laws and practices in employment, housing and health care, relationship recognition, and history of child abuse, harassment or interpersonal violence and likelihood of having access to mental health and substance abuse prevention and treatment services. The 2015 National Survey on Drug Use and Health (NSDUH, 2015)3 found that LGBTQ persons 18 years of age and over were over twice as likely to misuse prescription pain relievers (10.4% vs. 4.5%), heroin (.9% vs. .3%) and any illicit drug (39.1% vs. 17.1%) than sexual majority adults. In addition, sexual minority adults, 18 and over, were twice as likely than sexual majority adults to have reported any mental illness in the past year (37.4% vs. 17.1%) and over three times more likely to report a serious mental illness in the past year (13.1% vs. 3.6%)3. LGBTQ individuals often are more reluctant to seek treatment or disclose their sexual orientation during treatment out of concern that treatment providers might be unaware of their specific needs or might be hostile to them. Unique concerns of LGBTQ persons may deter some patients and providers from initiating potentially life-saving treatment for opioid use disorder. Unique concerns LGBTQ persons may have include questions about how treatment will affect adherence to antiretroviral therapy (ART) for people living with HIV, pre-exposure prophylaxis (PrEP) for those at risk of acquiring HIV, and hormone therapy for transgender patients. Other questions that LBGTQ individuals may have include how might MAT, such as buprenorphine and methadone, interact with hormone therapy, ART, and PrEP, and are there potential medication interactions that could impact their treatment adherence or health?

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Many LGBTQ individuals may have a co-occurring mental health disorder that either led to a substance abuse problem or is perpetuating their addiction. When considering which treatment option is best for an LGBTQ individual, there should be a focus on addressing any co-occurring disorders to allow for the highest chance of sustained sobriety while in recovery. Cognitive behavioral therapy (CBT) and cognitive processing therapy (CPT) are evidence based interventions that have been shown to be efficacious in treating OUD and trauma-based stress disorders, respectively. These frameworks are particularly relevant for LGBTQ people with an opioid use disorder mediated by posttraumatic stress symptoms. The Fenway Institute recommends that providers need to help LGBTQ patients recognize the adverse impacts of minority stress, as they are more likely to attribute the effects of external stressors to personal failures. Strategies identified by the Fenway Institute for helping LGBTQ patients recognize the effects of external stressors include: facilitating emotional awareness, regulation, and acceptance; empowering assertive communication; restructuring harmful minority stress cognitions; validating the unique strengths of LGBTQ people; and fostering supportive relationships with the LGBTQ community and allies. Persons Experiencing Homelessness. Opioid overdose is one of the major causes of death among people experiencing homelessness. Individuals experiencing homelessness are nine times more likely to die from an overdose than those who were stably housed. 81% of overdose deaths were caused by opioids among those experiencing homelessness compared to 61% of all adults, nationally, The association between mental illness and substance-related disorders is well established. Individuals experiencing homelessness rarely have substance use disorders alone. A recent national study found that 75% of patients experiencing homelessness with a past-year substance use disorder diagnosis, also had a comorbid nonsubstance related mental illness. In addition to substance use disorders and serious mental illnesses, many people experiencing homelessness also have acute and chronic physical health problems, and histories of trauma. These combined factors translate into persons experiencing homelessness having higher rates of substance abuse disorders, poorer health and mental health, and greater risk of mortality. The opioid epidemic affects individuals experiencing homelessness in ways that are different from those who are housed. Among persons experiencing homelessness, mental health conditions, use of substances other than opioids, and acute and chronic pain conditions all are highly prevalent. In addition, persons experiencing homelessness more frequently have difficulty accessing ambulatory health care and integrated service delivery due to structural barriers. Common barriers include lack of insurance, available resources or programs, enabling services such as transportation and child care, stigma and discrimination, social support services, and a dearth of culturally competent health care providers who are knowledgeable about the needs of persons who are homeless and of the services needed to address them. Public housing policies that make persons with a substance abuse history ineligible for consideration also is a major barrier for persons experiencing homelessness. Additionally, persons experiencing homelessness also have disproportionately high rates of comorbid conditions that place them at risk for poor treatment adherence and recovery outcomes. Taken together, these conditions and circumstances pose problems not necessarily encountered by housed populations. Migrant Farm Workers. The opioid crisis has touched all sectors of America’s patient population, especially medically underserved, vulnerable patients such as migrant farm workers. Migrant farm workers are largely non–English speaking, and nearly half are not authorized to work in the United States. Migrant farm workers often have to cope with the combined effects of low incomes, poor housing conditions, exclusion from labor law protections, lack of access to health care, social stigma towards immigrants, the threat of deportation, and high rates of workplace injuries and illnesses. In addition, the rate of fatal work-related injuries among agricultural workers is seven times higher than the rate among workers overall and two times higher than that for construction workers and those employed in the mining industry. These social and economic stressors and conditions place them at increased risk for depressive symptoms and other behavioral health disorders. Increased risk for injury, pain, stigma and discrimination would suggest that migrant farm workers are at increased risk for OUD. Yet, there is very little data about how migrant farm workers are being affected by the opioid crisis. The mortality rate of working-age adults in rural areas is skyrocketing due to opioid overdoses. Just under half of rural Americans say they have been directly impacted by opioid abuse and three in four farmers say it would be easy for someone in their community to access opioids illegally. According to a recent study commissioned by the National Farmers Union and the American Farm Bureau Federation, almost 75 percent of farmers and farm workers report having either taken an illegal dose of painkillers, are addicted, or know someone who is. The Migrant Farmworker’s Clinician’s Network has identified six “core components of safe, team-based opioid prescribing for primary care settings that serve migrant farm workers. These components include: 1) leadership and consensus (prioritize safe, more selective and more cautious opioid prescribing); 2) use of a registry to proactively manage patients (ensure that care is safe and appropriate and that results of chronic opioid therapy improvement activities are monitored; 3) revise policies and standards of care for health care team members (achieve safer opioid prescribing and chronic opioid therapy management); 4) use a patient-centered approach (ensure that care is safe and appropriate; 5) care for complex patients (develop policies and resources to ensure that patients who become addicted to opioids are identified and provided with appropriate care, either in the care setting or by outside referral); and 6) measure success (continuously monitor progress and improve services).

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5th Annual Communities of Practice Conference

Year 3 Research Projects

METHODS Systematic Review. In the first phase, we will conduct a systematic review of the literature using the PRISMA 2009 Checklist to identify how medical students and health care providers are being taught to screen for and respond to opioid use in general, and the needs of vulnerable populations, including LGBTQ individuals, persons experiencing homelessness, and migrant farm workers, in particular. The purpose of this review is to identify how medical schools are training students to address the opioid crisis in general, and the needs of vulnerable populations, in particular, and the evidence base for effective medical education curricula. We will conduct a systematic review of the medical education literature to identify how medical schools are teaching students about OUD screening, treatment, referral, recovery, and relapse. This exploration will also include identifying topics, capstones, and other educational elements in medical education that prepare students to address the needs of vulnerable populations relative to OUD. Research findings will be used to make recommendations for model OUD screening, treatment, and referral protocols and policies for the training of medical students. Additionally, we will link the core components of OUD training to present ACGME competencies. This step will ensure ease of implementation by medical schools, reduce redundancy of content, as well as streamline content to reduce time and effort by linking to extant content. Patient Focus Groups on OUD. In the second phase, we will conduct two patient focus groups, each with about 10-12 participants, recruited from our three partnering national organizations (Fenway Institute, Migrant Farmworkers Clinician Network, and National Healthcare Council for the Homeless) to discuss their experiences and expectation of health care providers relative to OUD. Focus group participants will be asked six open-ended questions about their expectations and/or experiences about how health care providers are addressing OUD service needs of LGBTQ individuals, persons experiencing homelessness, and migrant farm workers. One CHC from each of the three national partners will be identified that serve patients from urban areas and the other that serves patients from rural areas. Each focus group will be led by a facilitator and supported by a recorder. All sessions will be taped for later analysis. We will subcontract with the national partners to provide an incentive to patients who participate in the focus group. Human subject research approval will be obtained from the MMC IRB by the Center Director. Provider OUD Surveys. Ten health care providers from an urban and a rural community health center affiliated with each of our three national partners will be recruited to complete a short survey about how they and their clinic address the opioid crisis. The survey will address prevention, treatment, education and training, referrals and relapse prevention. Respondents will be provided a $25 gift card as an incentive for completing the survey. The provider survey will be developed jointly by national partner/clinic staff and MMD investigators. The survey will be submitted to the MMC IRB approval. Community of Practice. At the annual COP meeting, members will be asked to translate OUD patient and provider focus group and survey responses into medical school curricular recommendations. Topics may include teaching students how to recognize and address the effect of stigma and discrimination on patient readiness for treatment, how to assess patient coping styles and skills needed to manage stress associated with self-esteem, access to resources, “coming out” process, attitudes from others regarding social status, sexual orientation, family alienation, etc. COP members will be asked to consider the role of family, friends, and social or community services as a vital component of treatment and support structure to enhance treatment adherence. In addition, they will be asked to discuss culturally appropriate components in treatment that address relevant legal issues and the inherent issues that may arise in addressing medical, social, and financial needs of LGBT individuals, persons experiencing homelessness, and migrant farm workers. COP members also will be asked to discuss the integration of patient and clinic recommendations into guidelines for medical education curriculum with an emphasis on addressing the needs of vulnerable populations. This information will be used to make recommendations to medical schools on how to incorporate training about opioid misuse into medical education curriculum with an emphasis on vulnerable populations. In addition, COP members will be asked to identify key clinic related issues needed to provide culturally competent care for persons experiencing OUD including establishment of administrative priorities, naloxone and medical assisted treatment. integrated and comprehensive, team-based care, providing culturally competent care for vulnerable populations, and the role of technology and data in overcoming treatment barriers, ensuring continuity of care, and evaluation of clinic and provider effectiveness. This discussion will address a range of topics, including leveraging of EHR data, social media, CLAS standards, legal issues, and discussion of living wills, powers of attorney, and advance directives, restrictions imposed by HIPAA, as well as establishing a referral base to assist patients in securing needed services. Research findings will be disseminated through professional conferences and a minimum of one peer reviewed publication for each research project. In addition, each policy brief, per topic will be disseminated to a minimum of six national accrediting boards, professional societies, and health care provider organizations. The COP curricular recommendations on OUD will be translated into curricular modules and disseminated broadly through national accrediting boards, professional societies, and health care provider organizations, professional meetings, scholarly publications, and social media.

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Year 3 Research Projects

5th Annual Communities of Practice Conference

REFERENCES (PARTIAL LIST): HOMELESS A. Bachhuber, M. D. M. M., Christopher B. Roberts, M. P. H., Metraux, S., & Montgomery, A. (2015). Screening for homelessness among individuals initiating medication-assisted treatment for opioid use disorder in the Veterans Health Administration (Vol. 11). Cherpitel, C. J., Ye, Y., Zemore, S. E., Bond, J., & Borges, G. (2015). THE EFFECT OF CROSS-BORDER MOBILITY ON ALCOHOL AND DRUG USE AMONG MEXICAN-AMERICAN RESIDENTS LIVING AT THE U.S–MEXICO BORDER. Addict Behav, 50, 28-33. doi:10.1016/j.addbeh.2015.06.008 Cheung, A., Somers, J. M., Moniruzzaman, A., Patterson, M., Frankish, C. J., Krausz, M., & Palepu, A. (2015). Emergency department use and hospitalizations among homeless adults with substance dependence and mental disorders. Addiction Science & Clinical Practice, 10, 17. doi:10.1186/s13722-015-0038-1 Hall, G., Walters, S., Gould, H., & Lim, S. (2018). Housing versus treatment first for supportive housing participants with substance use disorders: A comparison of housing and public service use outcomes. Substance Abuse, 1-7. doi:10.1080/08897077.2018.1449049 Kerman, N., Sylvestre, J., Aubry, T., & Distasio, J. (2018). The effects of housing stability on service use among homeless adults with mental illness in a randomized controlled trial of housing first. BMC Health Services Research, 18, 190. doi:10.1186/s12913-018-3028-7 Palepu, A., Gadermann, A., Hubley, A. M., Farrell, S., Gogosis, E., Aubry, T., & Hwang, S. W. (2013). Substance Use and Access to Health Care and Addiction Treatment among Homeless and Vulnerably Housed Persons in Three Canadian Cities. PLoS ONE, 8(10), e75133. doi:10.1371/journal. pone.0075133 Parpouchi, M., Moniruzzaman, A., Rezansoff, S. N., Russolillo, A., & Somers, J. M. (2017). Characteristics of adherence to methadone maintenance treatment over a 15-year period among homeless adults experiencing mental illness. Addictive Behaviors Reports, 6, 106-111. doi:10.1016/j. abrep.2017.09.001

LGBTQ Buttram, M. E., Kurtz, S. P., Surratt, H. L., & Levi-Minzi, M. A. (2014). Health and Social Problems Associated with Prescription Opioid Misuse Among a Diverse Sample of High Risk Substance-Using MSM. Substance Use & Misuse, 49(3), 277-284. doi:10.3109/10826084.2013.828754 Corliss, H. L., Rosario, M., Wypij, D., Wylie, S. A., Frazier, A. L., & Austin, S. B. (2010). Sexual Orientation and Drug Use in a Longitudinal Cohort Study of U.S. Adolescents. Addict Behav, 35(5), 517-521. doi:10.1016/j. addbeh.2009.12.019 Li, D. H., & Mustanski, B. (2018). Prevalence and Correlates of Prescription Drug Misuse Among a Racially Diverse Sample of Young Sexual Minority Men. LGBT Health, 5(2), 95-104. doi:10.1089/lgbt.2017.0125

MIGRANT FARMWORKERS Borges, G., Cherpitel, C. J., Orozco, R., Zemore, S. E., Wallisch, L., MedinaMora, M.-E., & Breslau, J. (2016). Substance Use and Cumulative Exposure

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to American Society: Findings From Both Sides of the US–Mexico Border Region. American Journal of Public Health, 106(1), 119-127. doi:10.2105/ AJPH.2015.302871 Garcia, V. (2007). Meeting a Binational Research Challenge: Substance Abuse Among Transnational Mexican Farmworkers in the United States. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association, 23(Suppl), 61-67. doi:10.1111/j.1748-0361.2007.00125.x Robertson, A. M., Lozada, R., Pollini, R. A., Rangel, G., & Ojeda, V. D. (2012). Correlates and contexts of U.S. injection drug initiation among undocumented Mexican migrant men who were deported from the United States. AIDS and Behavior, 16(6), 1670-1680. doi:10.1007/s10461-0110111-z Rosales, C., Ortega, M. I., De Zapien, J. G., Paniagua, A. D. C., Zapien, A., Ingram, M., & Aranda, P. (2012). The US/Mexico Border: A Binational Approach to Framing Challenges and Constructing Solutions for Improving Farmworkers’ Lives. International Journal of Environmental Research and Public Health, 9(6), 2159-2174. doi:10.3390/ijerph9062159 Zhang, X., Martinez-Donate, A. P., Nobles, J., Hovell, M. F., Rangel, M. G., & Rhoads, N. M. (2015). Substance Use Across Different Phases Of The Migration Process: A Survey Of Mexican Migrants Flows. Journal of immigrant and minority health / Center for Minority Public Health, 17(6), 1746-1757. doi:10.1007/s10903-014-0109-5

MEDICAL EDUCATION Korthuis, P., McCarty, D., Weimer, M., & et al. (2017). Primary care–based models for the treatment of opioid use disorder: A scoping review. Annals of Internal Medicine, 166(4), 268-278. doi:10.7326/M16-2149 Zule, W. A., Oramasionwu, C., Evon, D., Hino, S., Doherty, I. A., Bobashev, G. V., & Wechsberg, W. M. (2016). Event-level analyses of sex risk and injection risk behaviors among nonmedical prescription opioid users. The American journal of drug and alcohol abuse, 42(6), 689-697. doi:10.1080/0 0952990.2016.1174706

UNCATEGORIZED REFERENCES 1. Abuse NIoD. Overdose Death Rtes. 2018; Opioid overdose Death rates. Available at: https://www.drugabuse.gov/related-topics/ trends-statistics/overdose-death-rates. Accessed 12/7/2018, 2018. 2. Crane E. The CBHSQ Report: Emergency Department Visits Involving Narcotic Pain Relievers. In: Substance Abuse and Mental Health Services Administration CfBHSaQ, ed. Rockville, MD: USDHHS; 2015. 3. Medley G, Lipari RN, Bose J, Cribb DS, Kroutil LA, McHenry G. Sexual orientation and estimate of adult substance use and mental health: Results from the 2015 National Survey on Drug Use and Health. In: Administration SAaMHS, ed. WA DC: Substance Abuse and Mental Health Service Administration; 2016: http://www.samhsa.gov/data. Accessed 12/11/2018.

5th Annual Communities of Practice Conference

Year 3 Research Projects

YEAR 3 SYSTEMATIC REVIEW

Opioid Misuse AUTHORS R. Lyle Cooper, Ph.D., MSSW, Paul Juarez, Ph.D., Matthew Morris, Ph.D. Aramandla Ramesh, Ph.D., Mohammad Tabatabai, Ph.D. Thomas A. Arcury, Ph.D., Leandro Mena, M.D., M.P.H., and Patricia Mathews-Juarez, Ph.D.

BACKGROUND The opioid crisis has worsened in recent years. In 2011, more than 366,000 people were treated in emergency departments for misusing prescription opioids – an over two-fold increase since 2005. In 2014, almost 2 million Americans abused or were dependent on prescription opioids. Additionally, as many as 25% of people who receive prescription opioids for non-cancer pain in primary care settings struggle with addiction. The potential for fatal overdose distinguishes opioids from other drugs. In 2015, more than 33,000 deaths were attributed to opioid overdose. More than 60% of drug overdoses involve opioids and nearly half of all opioid deaths are due to prescriptions. The recent surge in illicit opioid overdoses also has been driven by heroin and illegally-made drugs, such as fentanyl. The face of the opioid epidemic also is evolving. While the epidemic started in rural America, data from the 2015 National Survey on Drug Use and Health show that opioid misuse and addiction are now as prevalent in urban and suburban areas. A recent U.S. Department of Health and Human Services (HHS) study found that the proportion of the population using prescription opioids is similar across large metropolitan (36.0%), small metropolitan (40.1%), and non-metropolitan (39.9%) areas. Overdose is also a leading cause of death for individuals returning to the community from prison, who disproportionately are African Americans and Latinos. American Indian/Alaska Native populations also have been disproportionately impacted compared to other communities (e.g., in terms of heroin use).

PURPOSE The efforts to address the opioid crisis reveal some common needs across all communities in general, and vulnerable populations specifically, including persons who are LGBTq, homeless, and/or migrant farmworkers. Discrimination, implicit bias, lack of access to care and other social factors create unique challenges that both increase risk for opioid use and misuse and barriers to treatment. Our capacity to respond to the opioid epidemic is largely dependent upon capacity of the health care system to provide a spectrum of opioid services, from prevention to medically assisted treatment. Little is known about how medical schools are preparing future physicians to address this crisis. Even less is known about how they are preparing students to address the unique needs of vulnerable populations.

METHODS We will conduct a systematic review literature using the PRISMA 2009 Checklist to identify how medical students and healthcare providers are being taught to screen for and respond to opioid use in general, and the needs of LGBTq populations, homeless persons, and migrant farm workers, in particular. In addition, we will work with our Community of Practice to develop and conduct a survey of the three vulnerable populations as to how their health care providers have addressed the opioid crisis with them or their family members.

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Year 3 Research Projects

5th Annual Communities of Practice Conference

REFERENCES PERSONS EXPERIENCING HOMELESSNESS 1. A. Bachhuber, M. D. M. M., Christopher B. Roberts, M. P. H., Metraux, S., & Montgomery, A. (2015). Screening for homelessness among individuals initiating medicationassisted treatment for opioid use disorder in the Veterans Health Administration (Vol. 11). 2. Cherpitel, C. J., Ye, Y., Zemore, S. E., Bond, J., & Borges, G. (2015). THE EFFECT OF CROSS-BORDER MOBILITY ON ALCOHOL AND DRUG USE AMONG MEXICAN-AMERICAN RESIDENTS LIVING AT THE U.S–MEXICO BORDER. Addict Behav, 50, 28-33. doi:10.1016/j.addbeh.2015.06.008 3. Cheung, A., Somers, J. M., Moniruzzaman, A., Patterson, M., Frankish, C. J., Krausz, M., & Palepu, A. (2015). Emergency department use and hospitalizations among homeless adults with substance dependence and mental disorders. Addiction Science & Clinical Practice, 10, 17. doi:10.1186/ s13722-015-0038-1 4. Hall, G., Walters, S., Gould, H., & Lim, S. (2018). Housing versus treatment first for supportive housing participants with substance use disorders: A comparison of housing and public service use outcomes. Substance Abuse, 1-7. doi:10.10 80/08897077.2018.1449049 5. Kerman, N., Sylvestre, J., Aubry, T., & Distasio, J. (2018). The effects of housing stability on service use among homeless adults with mental illness in a randomized controlled trial of housing first. BMC Health Services Research, 18, 190. doi:10.1186/s12913-018-3028-7 6. Palepu, A., Gadermann, A., Hubley, A. M., Farrell, S., Gogosis, E., Aubry, T., & Hwang, S. W. (2013). Substance Use and Access to Health Care and Addiction Treatment among Homeless and Vulnerably Housed Persons in Three Canadian Cities. PLoS ONE, 8(10), e75133. doi:10.1371/journal.pone.0075133 7. Parpouchi, M., Moniruzzaman, A., Rezansoff, S. N., Russolillo, A., & Somers, J. M. (2017). Characteristics of adherence to methadone maintenance treatment over a 15-year period among homeless adults experiencing mental illness. Addictive Behaviors Reports, 6, 106-111. doi:10.1016/j. abrep.2017.09.001

LGBTQ 8. Buttram, M. E., Kurtz, S. P., Surratt, H. L., & Levi-Minzi, M. A. (2014). Health and Social Problems Associated with Prescription Opioid Misuse Among a Diverse Sample of High Risk Substance-Using MSM. Substance Use & Misuse, 49(3), 277-284. doi:10.3109/10826084.2013.828754 9. Corliss, H. L., Rosario, M., Wypij, D., Wylie, S. A., Frazier, A. L., & Austin, S. B. (2010). Sexual Orientation and Drug Use in a Longitudinal Cohort Study of U.S. Adolescents. Addict Behav, 35(5), 517-521. doi:10.1016/j.addbeh.2009.12.019

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10. Li, D. H., & Mustanski, B. (2018). Prevalence and Correlates of Prescription Drug Misuse Among a Racially Diverse Sample of Young Sexual Minority Men. LGBT Health, 5(2), 95-104. doi:10.1089/lgbt.2017.0125

MIGRANT FARMWORKERS 11. Borges, G., Cherpitel, C. J., Orozco, R., Zemore, S. E., Wallisch, L., Medina-Mora, M.-E., & Breslau, J. (2016). Substance Use and Cumulative Exposure to American Society: Findings From Both Sides of the US–Mexico Border Region. American Journal of Public Health, 106(1), 119-127. doi:10.2105/ AJPH.2015.302871 12. Garcia, V. (2007). Meeting a Binational Research Challenge: Substance Abuse Among Transnational Mexican Farmworkers in the United States. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association, 23(Suppl), 61-67. doi:10.1111/j.1748-0361.2007.00125.x 13. Robertson, A. M., Lozada, R., Pollini, R. A., Rangel, G., & Ojeda, V. D. (2012). Correlates and contexts of U.S. injection drug initiation among undocumented Mexican migrant men who were deported from the United States. AIDS and Behavior, 16(6), 1670-1680. doi:10.1007/s10461-011-0111-z 14. Rosales, C., Ortega, M. I., De Zapien, J. G., Paniagua, A. D. C., Zapien, A., Ingram, M., & Aranda, P. (2012). The US/Mexico Border: A Binational Approach to Framing Challenges and Constructing Solutions for Improving Farmworkers’ Lives. International Journal of Environmental Research and Public Health, 9(6), 2159-2174. doi:10.3390/ijerph9062159 15. Zhang, X., Martinez-Donate, A. P., Nobles, J., Hovell, M. F., Rangel, M. G., & Rhoads, N. M. (2015). Substance Use Across Different Phases Of The Migration Process: A Survey Of Mexican Migrants Flows. Journal of immigrant and minority health / Center for Minority Public Health, 17(6), 1746-1757. doi:10.1007/s10903-014-0109-5

MEDICAL EDUCATION 16. Korthuis, P., McCarty, D., Weimer, M., & et al. (2017). Primary care–based models for the treatment of opioid use disorder: A scoping review. Annals of Internal Medicine, 166(4), 268278. doi:10.7326/M16-2149 17. Zule, W. A., Oramasionwu, C., Evon, D., Hino, S., Doherty, I. A., Bobashev, G. V., & Wechsberg, W. M. (2016). Event-level analyses of sex risk and injection risk behaviors among nonmedical prescription opioid users. The American journal of drug and alcohol abuse, 42(6), 689-697. doi:10.1080/00952 990.2016.1174706

5th Annual Communities of Practice Conference

Year 3 Research Projects

YEAR 3 SYSTEMATIC REVIEW

Sexual Violence among Women who are LGBTQ, Homeless, and Migrant Farm Workers AUTHORS Paul Juarez, Ph.D., Aramandla Ramesh, Ph.D., Matthew Morris, Ph.D., R. Lyle Cooper, Ph.D., MSSW, Mohammad Tabatabai, Ph.D. Thomas A. Arcury, Ph.D., Beth Shinn, PhD, Leandro Mena, M.D., M.P.H., and Patricia Mathews-Juarez, Ph.D.

BACKGROUND Women who have sex with women (WSW), homeless, and migrant farmworkers are at increased risk for sexual violence due to their social status in our society. Social conditions experienced by women who have sex with women (WSW) and transgender women, migrant farmworkers, and homeless persons increase risk and/or lead to behaviors that increase risk for sexual violence. These conditions also pose challenges for health and mental health providers. Compared with never WSW, WSW begin sexual activities earlier, engage in sex, and unprotected sex more frequently, and more often trade sex for money or drugs. In combination, these behaviors elevate their risk for violence victimization, as well as for STIs/HIV, tobacco use, alcohol use, heroin, and cocaine, compared to never WSW. These behaviors further increase risk for sexual violence. Among homeless persons, young women who have sex with women (WSW) are at greatest risk for sexual violence. Homeless young women and teens are more likely to engage in survival sex, use drugs, and be in dangerous and vulnerable situations with little or no protection from violent sexual partners. Sexual violence among women within the farmworker community also is a pervasive problem. Ninety percent of female farmworkers in the United States report that workplace sexual violence is a “major problem.” Farmworker women who are victims of sexual violence often suffer in silence. They may have fears of losing their jobs, adverse action by law enforcement including immigration officials, and other forms of retaliation against them or their families. In addition, victims may not know their legal rights. They may have no one to reach out to in an unfamiliar community, isolated by language, distance, culture and lack of transportation.

PURPOSE Sexual violence poses unique risk factors and sequelae for WSW, homeless women, and migrant farm worker women. Each group is vulnerable to sexual violence due to broader social conditions and fears which serve as barriers for them to seek and/or receive care. Perpetrators of sexual violence, frequently use these fears and conditions to exert power and control over their victims. Health care providers may not be aware of the increased risk for sexual violence experienced by these vulnerable populations or having any training on how to screen for and/or address the problem.

METHODS We propose to conduct a systematic review of the literature using the PRISMA 2009 Checklist to identify how medical students are being to screen for sexual violence among WSW, homeless, and migrant farm worker women. The purpose of this review is to identify how medical schools are training students to screen for sexual violence and engage appropriate services and resources to assist them. In addition, we propose to conduct a survey among WSW, homeless, and women migrant farm worker constituents of our CoP partners about whether they have ever been screened for sexual violence by their health care providers and the outcome of the screening. In addition, we will develop curriculum tools which can be used to teach medical students about how to screen for and address sexual violence among WSW, homeless women, and women migrant farm workers.

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Year 3 Research Projects

5th Annual Communities of Practice Conference

REFERENCES 1. Austin, S. B., Jun, H.-J., Jackson, B., Spiegelman, D., RichEdwards, J., Corliss, H. L., & Wright, R. J. (2008). Disparities in Child Abuse Victimization in Lesbian, Bisexual, and Heterosexual Women in the Nurses’ Health Study II. J Womens Health (Larchmt), 17(4), 597-606. doi:10.1089/ jwh.2007.0450 2. Bell, A. V., Ompad, D., & Sherman, S. G. (2006). Sexual and Drug Risk Behaviors Among Women Who Have Sex With Women. American Journal of Public Health, 96(6), 1066-1072. doi:10.2105/AJPH.2004.061077 3. Broll, R., & Huey, L. (2017). “Every Time I Try to Get Out, I Get Pushed Back”: The Role of Violent Victimization in Women’s Experience of Multiple Episodes of Homelessness. Journal of Interpersonal Violence, 0886260517708405. doi:10.1177/0886260517708405 4. Dank, M., Lachman, P., Zweig, J. M., & Yahner, J. (2014). Dating Violence Experiences of Lesbian, Gay, Bisexual, and Transgender Youth. Journal of youth and adolescence, 43(5), 846-857. doi:10.1007/s10964-013-9975-8 5. Gilmore, A. K., Koo, K. H., Nguyen, H. V., Granato, H. F., Hughes, T. L., & Kaysen, D. L. (2014). Sexual Assault, Drinking Norms, and Drinking Behavior among a National Sample of Lesbian and Bisexual Women. Addict Behav, 39(3), 630-636. doi:10.1016/j.addbeh.2013.11.015 6. Griner, S. B., Vamos, C. A., Thompson, E. L., Logan, R., Vázquez-Otero, C., & Daley, E. M. (2017). The Intersection of Gender Identity and Violence: Victimization Experienced by Transgender College Students. Journal of Interpersonal Violence, 0886260517723743. doi:10.1177/0886260517723743 7. Heerde, J. A., Scholes-Balog, K. E., & Hemphill, S. A. (2015). Associations Between Youth Homelessness, Sexual Offenses, Sexual Victimization, and Sexual Risk Behaviors: A Systematic Literature Review. Archives of sexual behavior, 44(1), 181-212. doi:10.1007/s10508-014-0375-2 8. Hequembourg, A. L., Livingston, J. A., & Parks, K. A. (2013). SEXUAL VICTIMIZATION AND ASSOCIATED RISKS AMONG LESBIAN AND BISEXUAL WOMEN. Violence Against Women, 19(5), 634-657. doi:10.1177/1077801213490557 9. Long, S. M., Ullman, S. E., Long, L. M., Mason, G. E., & Starzynski, L. L. (2007). Women’s Experiences of MalePerpetrated Sexual Assault by Sexual Orientation. Violence and victims, 22(6), 684-701. doi:10.1891/088667007782793138 10. Lyons, T., Shannon, K., Richardson, L., Simo, A., Wood, E., & Kerr, T. (2016). Women who use drugs and have sex with women in a Canadian setting: Barriers to treatment enrollment and exposure to violence and homelessness. Archives of sexual behavior, 45(6), 1403-1410. doi:10.1007/ s10508-015-0508-2

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11. Mattocks, K. M., Sadler, A., Yano, E. M., Krebs, E. E., Zephyrin, L., Brandt, C., . . . Haskell, S. (2013). Sexual Victimization, Health Status, and VA Healthcare Utilization Among Lesbian and Bisexual OEF/OIF Veterans. Journal of General Internal Medicine, 28(Suppl 2), 604-608. doi:10.1007/s11606-0132357-9 12. Pyra, M., Weber, K., Wilson, T. E., Cohen, J., Murchison, L., Goparaju, L., & Cohen, M. H. (2014). Sexual Minority Status and Violence Among HIV Infected and At-Risk Women. Journal of General Internal Medicine, 29(8), 1131-1138. doi:10.1007/s11606-014-2832-y 13. Smith, L. R., Yore, J., Triplett, D. P., Urada, L., Nemoto, T., Raj, A., . . . Team, T. S. (2017). Impact of Sexual Violence Across the Lifespan on HIV Risk Behaviors Among Transgender Women and Cisgender People Living With HIV. JAIDS Journal of Acquired Immune Deficiency Syndromes, 75(4), 408-416. doi:10.1097/qai.0000000000001423 14. Tsai, A. C., Weiser, S. D., Dilworth, S. E., Shumway, M., & Riley, E. D. (2015). Violent Victimization, Mental Health, and Service Utilization Outcomes in a Cohort of Homeless and Unstably Housed Women Living With or at Risk of Becoming Infected With HIV. American Journal of Epidemiology, 181(10), 817826. doi:10.1093/aje/kwu350 15. Tyler, K. A., Whitbeck, L. B., Hoyt, D. R., & Cauce, A. M. (2004). Risk Factors for Sexual Victimization Among Male and Female Homeless and Runaway Youth. Journal of Interpersonal Violence, 19(5), 503-520. doi:10.1177/0886260504262961 16. Wirtz, A. L., Poteat, T. C., Malik, M., & Glass, N. (2018). Gender-Based Violence Against Transgender People in the United States: A Call for Research and Programming. Trauma, Violence, & Abuse, 1524838018757749. doi:10.1177/1524838018757749 17. Wong, L. H., Shumway, M., Flentje, A., & Riley, E. D. (2016). Multiple types of childhood and adult violence among homeless and unstably housed women in San Francisco. Violence and victims, 31(6), 1171-1182. doi:10.1891/0886-6708. VV-D-15-00132 18. Young, D. A., Shumway, M., Flentje, A., & Riley, E. D. (2017). The relationship between childhood abuse and violent victimization in homeless and marginally housed women: The role of dissociation as a potential mediator. Psychological Trauma: Theory, Research, Practice, and Policy, 9(5), 613-621. doi:10.1037/tra0000288

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YEAR 3 POLICY BRIEF

Medical Education Efforts to Manage the Opioid Epidemic Conducted by: Paul D. Juarez, Michael Paul, Tyler Dixon, & Aramandla Ramesh

BACKGROUND Rates of substance use disorders, including opioid misuse, continue to rise despite national initiatives. Opioid overdose fatalities include deaths from natural opioids (morphine and codeine), semi-synthetic opioids (oxycodone, hydrocodone), synthetic opioids (prescription and illicit fentanyl, tramadol), methadone, and heroin.1-4,5 From 1999 to 2017, there were 399,230 deaths attributed to opioids in the U.S.1 In 2017, a total of ~47,600 opioid overdose deaths occurred, accounting for 67.8% of all overdose deaths, an increase of 9.6%, from 19.8 to 21.7 deaths per 100,000.1 From 2015 to 2016, rates of overdose deaths for synthetic opioids, natural/ semisynthetic opioids, and heroin increased by 100%, 12.8%, and 19.5%, respectively.4 Medical schools and teaching hospitals are on the front lines in our communities dealing with the opioid epidemic: responding with new approaches to prevent, identify, and treat pain and substance use disorders, delivering pain management and addiction education, and leading efforts in this area to advance medical research and promote innovations in clinical care. Yet, there remains no consensus on how to teach medical students and residents about their role and responsibilities in managing the opioid epidemic. Managing the opioid epidemic includes a wide breadth of knowledge and skills, including pain management, opioid prescribing, risk mitigation and stratification, medical assisted treatment, treating overdoses, alternative pain therapies, interprofessional team based care, and prevention counseling. The aim of this research is to identify and assess the extent to which medical schools prepares students to address the opioid epidemic with specific emphasis on vulnerable populations.

METHODS We conducted a systematic review of the literature using the 2009 PRISMA guidelines to identify original studies that focused on teaching medical students and residents the role of physicians in responding to the opioid epidemic. An electronic search was conducted in MEDLINE/ PubMed, PsycINFO, Web of Science, Scopus, Ingenta, Science Direct, and Google Scholar databases for articles published in English prior to February 2019. For Google Scholar, key terms were entered and related searches were reviewed. The first ten pages of the search for each of the key terms and related searches were reviewed. The search strategy cross-referenced keywords for opioid use, abuse, and misuse with keywords for teaching medical student and medical residents. It did not include other health professions training programs or continuing education of medical providers. It only included articles about education and training efforts that took place in US medical schools and residency training programs and only included articles written in English. These references were downloaded and entered into the citation manager.

RESULTS A total of 13,061 articles were identified through database searching. After duplicates were removed, 11,014 records remained. 291 records were excluded due to exclusion criteria (books = 92; book sections =145, conference proceedings = 13, generic = 19, and serials = 22) leaving 10,723. After a full-text review was completed, only 40 remained. After a full text of article reviews was conducted, only 27 remained. Of the 27 articles, 14 were identified from the review of seven databases, two articles were identified by Google Scholar, 11 articles were identified by both the review of seven databases and Google Scholar, and one was identified from references. One article was published before 2000, four articles were published between 2000 and 2009, and 22 were published from 2000 to 2018. Eight of the articles were recommendations for added curriculum on opioids, seven were surveys of knowledge and attitudes, and nine were evaluations of curriculum evaluations. Three (3) additional articles were reviews of secondary data. Of the nine articles that described curriculum interventions, eight of them resulted in statistically significant increases in knowledge (p=p.05) and only one was not significant. The interventions consisted primarily of didactic education with pre- post evaluations, seven were 2-8 hours of didactics, and two used a case based approach.

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RECOMMENDATIONS The dramatic increase in opioid misuse since 2000, has changed the need for medical education curriculum transformation to address opioid misuse. This review demonstrates that even a modest didactic educational intervention can have a significant impact on knowledge and attitudes of medical students towards opioid misuse and management. Articles that provided results of surveys (n=7) unanimously identified the need for national leadership in developing a core curriculum about opioid misuse.

REFERENCES 1. Centers for Disease Control and Prevention. 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States. Surveillance Special Report. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published August 31, 2018. Accessed [date] from https://www.cdc.gov/ drugoverdose/pdf/ pubs/2018- cdc-drug-surveillance-report.pdf 2. Centers for Disease Control and Prevention. Annual Surveillance Report of Drug-Related Risks and Outcomes — United States, 2017. Surveillance Special Report 1. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published August 31, 2017. Accessed [date] from https://www.cdc.gov/ drugoverdose/pdf/pubs/2017- cdc-drug-surveillance-report. Pdf

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3. Seth P, Scholl L, Rudd RA, Bacon S. Overdose Deaths Involving Opioids, Cocaine, and Psychostimulants- United States, 2015-2016. MMWR 2018; 67:349-358. doi: http://dx.doi. org/10.15585/mmwr.mm6712a1. 4. Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999–2016. NCHS Data Brief, no 294. Hyattsville, MD: National Center for Health Statistics. 2017. 5. Mattson CL, O’Donnell J, Kariisa M, Seth P, Scholl L, Gladden RM. Opportunities to Prevent Overdose Deaths Involving Prescription and Illicit Opioids, 11 States, July 2016–June 2017. MMWR Morb Mortal Wkly Rep 2018; 67:945–951. DOI: http://dx.doi.org/10.15585/mmwr.mm6734a2

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YEAR 3 POLICY BRIEF

Medical Education Efforts to Address Sexual Violence Conducted by: Paul D. Juarez, Michael Paul, Tyler Dixon, & Aramandla Ramesh

A SYSTEMATIC REVIEW OF MEDICAL EDUCATION EFFORTS TO ADDRESS SEXUAL VIOLENCE: EXECUTIVE SUMMARY The aim of this research is to identify and assess the extent to which medical schools prepares students to address sexual violence with specific emphasis on vulnerable populations.

STATEMENT OF THE PROBLEM Sexual violence is a common experience in the lives of both men and women[1]. Factors such as race, class, ethnicity, gender, sexual identity and social conditions, such as sex workers, homelessness, and migrant farm work may make persons particularly vulnerable to sexual assault. Marginalized populations are often the most vulnerable for sexual violence and often face the greatest obstacles to gaining protection and necessary services[2]. Sexual violence crosses all socioeconomic, racial, gender, and cultural boundaries and can have psychological, emotional, and physical effects on a survivor[3]. Current estimates suggest that one in six women and one in 33 men will experience attempted or completed rape (i.e., forced oral, anal, or vaginal penetration) in his or her lifetime.[4] While studies have shown that most female patients want to be asked about their experiences with sexual violence by their health care providers[5], few medical professionals screen any patients, female or male, for such trauma[6]. This may be due to a lack of training, time, or comfort on the part of the health care provider[7]. The effects of sexual violence aren’t always easy to deal with, but when diagnosed and with the right help and support they can be managed by the primary care team. Having a non-abusive relationship with a healthcare provider fosters mutual trust and promotes long-term health by allowing a survivor to feel taken care of in a relationship that is based on trust[8].

METHODS. We conducted a systematic review of the literature using the 2009 PRISMA guidelines to identify original studies that focused on teaching medical student to address sexual violence.

RESULTS. Only four studies were identified whose purpose was to teach medical students how to address sexual violence in their patients. Of those, three administered an intervention while none used a high quality research design to assess impact. Two of the studies used a pre-post no control intervention while the other used a time series design without a control group. Significant changes in student knowledge and attitudes were found at post exam for three studies but the change was not sustained at timepoint three in the one study that used a multiple time series design. Two of the interventions were 2-3 hour lectures and the third used three downloadable modules. Interventions were administered to students across all four years of medical school.

RECOMMENDATIONS. More research is needed to identify barriers to teaching medical students how to address sexual violence and the best strategies for undertaking it. The limited results of research on this topic add little to our knowledge of its perceived importance in academic medicine, the comfort level of providers in addressing it, or of effective strategies that prepare medical students to improve their knowledge, awareness and skills to effectively address it. Key stakeholders - Key stakeholders include but are not limited to academic medical institutions, medical education accreditation bodies, health care providers and students enrolled in health professions training programs, advocacy groups, public health officials, policymakers, health professions associations, and populations at risk.

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ISSUE One out of every six American women has been the victim of an attempted or completed rape in her lifetime (14.8% completed, 2.8% attempted). About 3% of American men—or 1 in 33—have experienced an attempted or completed rape in their lifetime.[4] In addition, Child Protective Services agencies substantiated, or found strong evidence to indicate that, 63,000 children a year, a majority of whom were between 12 and 17 years of age, were victims of sexual abuse[9]. Among victims under the age of 18, 34% were under the age of 12, while 66% of victims of sexual assault and rape were age 12-17 years of age[9]. Given the high rates of sexual violence and potential health impacts, it is therefore likely that most health care providers will come into contact with victims of sexual violence. Sexual assault of both men and women has received increased media attention in recent years, particularly in light of the Me2Movement and the surge of sexual abuse cases that have been uncovered in both the Catholic Church and the Boy Scouts. The enduring impact of sexual violence on the lives of survivors has been well documented. People who have been sexually victimized have been found to be more likely to suffer from chronic physical and mental health problems than those who have not been victimized, and believe that their health is fair or poor[10]. Other physical consequences of sexual violence include unintended pregnancy, chronic pain, gastrointestinal disorders, gynecological complications, genital injuries, and sexually transmitted disease[3]. Psychological response to being a victim of sexual assault include depression, anxiety, stress and fear, making it difficult to adjust or cope for some time afterward[11]. Female survivors of sexual violence visit the doctor more often than women who have not been victimized[12] Certain populations are at greater risk for sexual assault than others. Women, children, persons who are LGBTQ, experiencing homelessness, and/or migrant farmworkers all are at heightened risk for sexual violence due to social conditions such as stigma, discrimination, and segregation; social forces, including addictions, family breakdown, and mental illness; and structural forces such as lack of available low-cost housing, poor economic conditions, and insufficient mental health services. Despite their heightened risk, the unique needs of vulnerable populations experiencing sexual violence rarely are addressed in medical education due to “small numbers.” Many factors influence a survivors’ decision making in relation to reporting sexual violence. These include the individuals’ access to good medical care provided by knowledgeable and empathetic clinicians. Yet, it remains unclear how many medical schools provide teaching about sexual assault to undergraduate students, how it is carried out, and what impact it has. More research is needed that focuses upon measuring the effectiveness of sexual violence education in changing medical students’ negative attitudes and misperceptions about sexual violence.

BACKGROUND Medical students who go on to work in any specialty are likely to encounter patients who have experienced sexual violence, even though it is likely that this history is unlikely to be disclosed. Studies have shown that many medical students have a negative attitude towards persons who have experienced sexual violence, particularly men. A 2007 editorial in The Lancet, entitled “Medical students should be taught about rape”—called for the widespread teaching on sexual violence: “Victims of rape deserve a better response, and teaching future doctors how to respond would be a good start”.[13] Yet there is little evidence that this has yet happened. Doctors are likely to be confronted with victims of sexual violence in obstetrics and gynecology, family practice, emergency medicine, pediatrics, surgery and other specialties, but may have received no training in this area. Correct examination, evidence gathering, and immediate medical and mental health care all are essential to working with sexual violence survivors but these skills are often are lacking in medical education. In addition, communication in a sensitive and non-judgmental approach, medical requirements such as management of genital and non-genital injuries, emergency contraception and prevention or treatment of sexually transmitted infections including HIV, and psychosocial support are other clinical skills that may be warranted. A recent survey of medical schools in the United Kingdom found that only a quarter provide teaching about sexual assault, with many thinking that this topic is too specialist for the undergraduate curriculum. By contrast, other countries, such as Canada, routinely train medical students in how to deal with victims of sexual assault. A qualitative study of physicians from five different specialties undertaken to identify barriers to providing care for women who are sexual violence survivors, identified several factors which hindered their ability to fulfill their roles. They include: (1) internal barriers (e.g. discomfort with the topic of sexual assault); (2) physician-patient communication; and (3) system obstacles (e.g. competing priorities for time)[14]. In addition, males have been found to be more likely to adhere to rape myths and to view male rape victims more negatively than female victims.[15]

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METHODS We conducted a systematic review of the literature using the 2009 PRISMA guidelines[16] to identify original studies that focused on reducing medical student or health care provider bias towards LGBTQ persons. An electronic search was conducted in MEDLINE/ PubMed, PsycINFO, Web of Science, Scopus, Ingenta, Science Direct, and Google Scholar databases for articles in English published prior to February 2017. The search strategy cross-referenced keywords for sexual violence, sexual assault, sexual abuse and rape AND medical education, undergraduate medical education, medical school curriculum, and curriculum OR vulnerable populations (Lesbian, gay, bisexual, transsexual, LGBTQ, persons experiencing homelessness, migrant farmworkers). To be included in this systematic review, a study had to: 1) focus on undergraduate medical education, 2) be written in English; 3) be undertaken in a US medical schools 4) be published prior to January 2019.

RESULTS/KEY FINDINGS. Four studies were identified whose purpose was to teach medical students how to address sexual violence in their patients. Three administered an intervention while none used a high quality research design to assess impact. Two of these studies used a pre-post no control intervention while the other used a time series design without a control group. Significant changes in student knowledge and attitudes were found at post exam for three studies but the change was not sustained at time point three in the study that used a multiple time series design. Two of the interventions were 2-3 hour lectures and the third used three downloadable modules. Interventions were administered to students across all four years of medical school. None of the articles addressed the social circumstances, forces, and structures that increase risk for sexual violence among vulnerable populations.

DISCUSSION The lack of attention to teaching medical students how to address sexual violence in their patients therefore was unexpected and it is unclear why this is the case. It has been argued that in academic medicine, the attention to sexual violence should be addressed more thoroughly in residency training. However, men and women who have been sexually assaulted present for help in various healthcare settings, even if they may not disclose the actual assault. They should have access to optimal management, which starts with a physician’s awareness of their needs. This is the rationale why sexual violence needs to be taught early in the medical education process and not only in specialized residency training. In addition, there is a need for medical students to understand the social conditions and circumstances that increase risk for sexual violence by vulnerable populations.

LIMITATIONS In the United States, sexual violence is more commonly addressed in residency training programs than in undergraduate medical education. This was borne out by the number of research articles that were eliminated due to the exclusion criterion that they be limited to interventions that occurred during medical schools. A number of articles also were eliminated because they were undertaken in medical schools outside the United States. These additional articles suggest that US medical schools can build on work at other levels and from other countries in creating curricula.

RECOMMENDATIONS/NEXT STEPS While the American Medical Association has issued a policy statement on Family and Intimate Partner Violence (H-515.965), it has not specifically addressed the need for medical education to include sexual violence in the curriculum. A statement by the AMA and other medical professional associations about the importance of addressing sexual violence in the medical education curriculum would bring greater importance to this critically important topic.

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REFERENCES 1. Tjaden P., T., N., Prevalence, incidence and consequences of violence against women: Findings from the National Violence Against Women Survey, in U.S. Department of Justice, National Institute of Justice. 2000, U.S. Department of Justice, National Institute of Justice: WA DC. 2. The Advocates for Human Rights. Sexual Assault and Vulnerable Populations. Stop Violence Agaisnt Women 2018 [cited 2018 12/13]; Available from: http://www.stopvaw.org/sexual_assault_and_ vulnerable_populations. 3. Centers for Disease Control and Prevention. Sexual Violence: Consequences. Violence Prevention 2018 4/10/2018 [cited 2018 12/13]; Available from: https://www.cdc.gov/violenceprevention/ sexualviolence/consequences.html. 4. Tjaden P1, T.N., Allison CJ., Comparing violence over the life span in samples of same-sex and opposite-sex cohabitants. Violence Vict, 1999. 14(4): p. 13-25. 5. Littleton, H.L., C.R. Breitkopf, and A.B. Berenson, Correlates of anxiety symptoms during pregnancy and association with perinatal outcomes: a meta-analysis. American Journal of Obstetrics and Gynecology, 2007. 196(5): p. 424-432. 6. McAfee, R.E., Physicians and domestic violence: Can we make a difference? JAMA, 1995. 273(22): p. 1790-1791. 7. Stayton CD, D.M., Mutable influences on intimate partner abuse screening in health care settings: a synthesis of the literature. Trauma Violence Abuse, 2005. 6(4): p. 271-85. 8. Spinelli, F., The sexually abused man’s relationship with his physician. J Clin Case Rep 2016. 6: p. 893. 9. National Center for Victims of Crime. Child Sexual Abuse Statistics. 2018 [cited 2018 12/13]; Available from: http://victimsofcrime.org/ media/reporting-on-child-sexual-abuse/child-sexual-abuse-statistics.

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10. Golding, J.M., M.L. Cooper, and L.K. George, Sexual assault history and health perceptions: Seven general population studies. Health Psychology, 1997. 16(5): p. 417-425. 11. Office on Violence Against Women, US DOJ, Assessing Patients For Sexual Violence A Guide For Health Care Providers, N.S.V.R. Center, Editor. 2011: Enola, PA. p. 1-6. 12. Chivers-Wilson, K.A., Sexual assault and posttraumatic stress disorder: a review of the biological, psychological and sociological factors and treatments. McGill journal of medicine : MJM : an international forum for the advancement of medical sciences by students, 2006. 9(2): p. 111-118. 13. The Lancet, Medical students should be taught about rape. The Lancet, 2007. 369(9569): p. 1234. 14. Amin, P., R. Buranosky, and J.C. Chang, Physicians’ Perceived Roles, as Well as Barriers, Toward Caring for Women Sex Assault Survivors. Women’s health issues : official publication of the Jacobs Institute of Women’s Health, 2017. 27(1): p. 43-49. 15. Anderson, I. and A. Quinn, Gender differences in medical students’ attitudes towards male and female rape victims. Psychology, Health & Medicine, 2009. 14(1): p. 105-110. 16. Moher, D., et al., Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol, 2009. 62(10): p. 1006-12. 17. https://www.ncbi.nlm.nih.gov/pubmed/11479107

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Year 4 Research Projects

YEAR 4 RESEARCH TOPIC

Teaching Medical Students to Provide Affirming Care for LGBTQ Patients PI: Patricia Matthews-Juarez, PhD / Contact person: Paul D. Juarez, PhD Date funded: UH1HP30348/ 07/01/2016 – 06/30/2021

BACKGROUND There is increasing recognition of the need for health care providers to provide affirming care to persons who are LGBTQ1-3. On October 6, 2015, the U.S. Centers for Medicare and Medicaid Services (CMS)1 and the Office of the National Coordinator for Health Information Technology (ONC)2 announced that they will require that all electronic health record (EHR) systems certified under the Meaningful Use incentive program have the capacity to collect sexual orientation and gender identity (SO/GI) information from patients. The CMS final rule indicates that ‘‘CMS and ONC believe including SO/GI in the ‘demographics’ criteria represents a crucial step forward to improving care for LGBTQ communities.’’4 Yet the role of medical schools in ensuring students and residents are trained to provide affirming care continues to lag5-7. While there has been an increasing call for health care professionals to provide culturally appropriate care for LGBTQ patients, the teaching of future primary care providers how to provide affirming care is largely lacking in medical school curriculum5-7. A 2009-2010 survey administered to medical school deans about LGBTQ related content in medical education found that the median reported time dedicated to LGBTQ-related topics was small (e.g. 5 hours) and that the quantity, content covered, and perceived quality of instruction varied substantially8. While there is an increasing number of medical residency specialty and sub-specialty programs, including OB/GYN, Urology, and Surgery that have identified the need for residents to receive training in affirming care for transgender patients8-12 little curriculum time of medical schools currently is allotted to addressing the unique, affirming needs of other LBGQ patients13.

METHODS The research will be undertaken through three goals. The first goal is to conduct a systematic review of the literature on how medical students and residents are being taught to provide affirming care to LGBTQ patients. The second goal is to develop and administer a survey to assess the extent to which health care providers at community health centers are providing affirming care and barriers to implementation. This goal seeks to develop and administer a survey of health care providers at targeted community health centers to ascertain their level of knowledge, attitude, and awareness of affirming care and barriers to care. The survey will be conducted as a cross sectional study of knowledge, attitudes and awareness of health care providers at CHCs about affirming care for LGBTQ patients, the extent to which it is practiced in their clinic, and barriers to implementation. The third goal is to translate and broadly disseminate research findings as curriculum recommendations for medical schools, residency programs, and practicing health care providers.

IMPLICATIONS There is increased awareness of the need for health care professionals to provide culturally appropriate health care to all patients, including those who are LBGTQ. Yet, knowledge, attitudes and level of awareness of how to provider affirming care to LGBTQ patients is woefully deficient. Medical education curriculum needs to be revised to include the core elements of affirming care for LGBTQ patients. Affirming, curriculum modules will be developed, evaluated, and disseminated to health professions educators and advocates for LGBGQ health.

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RESEARCH DESCRIPTION TITLE: TEACHING MEDICAL STUDENTS AND RESIDENTS TO PROVIDE AFFIRMING CARE FOR PATIENTS WHO ARE LGBTQ STATEMENT OF THE PROBLEM Medical students and residents currently lack sufficient training on affirming care to patients who are LGBTQ and how to provide it. There has been an increasing call for health care providers to provide culturally appropriate, affirming care to persons who identify as LGBTQ1-3. On October 6, 2015, the U.S. Centers for Medicare and Medicaid Services (CMS)1 and the Office of the National Coordinator for Health Information Technology (ONC)2 announced that they will require that all electronic health record (EHR) systems certified under the Meaningful Use incentive program have the capacity to collect sexual orientation and gender identity (SO/GI) information from patients. The CMS final rule indicates that ‘‘CMS and ONC believe including SO/GI in the ‘demographics’ criteria represents a crucial step forward to improving care for LGBTQ communities.’’4 Yet the role of medical schools in ensuring students and residents are trained to provide affirming care continues to lag5-7. A 2009-2010 survey administered to medical school deans about LGBTQ related content in medical education found that the median reported time dedicated to LGBTQ-related topics was small (e.g. 5 hours) and that the quantity, content covered, and perceived quality of instruction varied substantially8. While there is an increasing number of medical residency specialty and sub-specialty programs, including OB/GYN, Urology, and Surgery that have identified the need for training in affirming care for transgender patients8-12, the need to provide affirming primary care to patients who are LGBTQ continues to be largely overlooked. Little curriculum time of medical schools currently is allotted to addressing the unique, affirming, primary health care needs of LGBTQ patients13.

TARGET POPULATIONS LGBTQ patients.

RESEARCH QUESTIONS OR HYPOTHESIS: 1. What is the evidence base for health care professionals providing affirming care to LGBTQ patients in community health care settings? 2. What are the core elements of the medical educational curriculum that can be revised and adapted to ensure students have the knowledge and skills to provide culturally competent health care to LGBTQ patients? 3. Will inclusion of education on affirming care for LGBTQ patients result in improved knowledge and attitudes among medical students and residents? 4. Will inclusion of education on affirming care for LGBTQ patients result in perceived improvements in patient care and outcomes?

WORK PLAN The research will be undertaken through three goals. The first goal is to conduct a systematic review of the literature on how medical students and residents are being taught to provide affirming care to LGBTQ patients. The second goal is to develop an affirming care curriculum that can be taught to medical students and residents. The third goal is to broadly disseminate research results to medical schools, residency programs and practicing health care providers through traditional and non-traditional venues.

PROJECT GOAL 1 To conduct a systematic review of the literature to identify how medical students and residents are being trained to provide affirming care to LGBTQ patients.

METHODOLOGY » We will use PRISMA guidelines to conduct a systematic review of the literature from 2005 until present using Scopus, PubMed, Web of Science, EBSCOhost, Google Scholar and PsycINFO. A systematic review will be conducted according to PRISMA guidelines. The search strategy cross-referenced keywords for LGBTQ populations (lesbian, gay, bisexual, transgender, gender identity, transsexual, gender reassignment, gender affirmation, genderqueer, gender nonconforming, gender dysphoria, transgender non-conforming/ TGNC) with keywords for medical students and residents (medical student, medical resident), and medical education (medical school curriculum, basic science, clinical, rotations, OSCE, standardized patient).

ANALYSIS » A systematic review of the literature will be conducted on how US medical school curricula addresses provision of affirming care for transgender patients using the PRISMA guidelines.

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Year 4 Research Projects

ANTICIPATED PRODUCTS » We will present findings of the systematic review at a minimum of two professional conferences per year. » We will submit a minimum one article for publication in a peer reviewed journal on how medical schools are teaching students and residents to provide affirming care to LGBTQ patients.

PROJECT GOAL 2 To work with our Community of Practice and national partners to develop and administer a survey to providers at community health centers about the extent and barriers to the provision of affirming care for LGBTQ patients.

METHODOLOGY » We will work with our consultants, the Fenway Institute, the Migrant Clinicians Network, and the National Health Care for the Homeless Council to develop and administer a survey to assess the extent to which health care providers at community health centers are aware of and are providing affirming care to LGBTQ patients. Core elements of affirming care will address a number of elements, including cultural awareness, staff training, waiting areas, bathrooms, fluency of terminology, and gender identity data.

ANALYSIS » A pre/post survey of knowledge and attitudes about affirming care will be administered to staff of targeted community health centers. » Survey results will be analyzed to identify the extent to which they address core elements of affirming care and barriers to achieving them.

ANTICIPATED PRODUCT » Research findings on the provision of affirming care will be disseminated broadly to the academic medicine community through the publication of at least one article in a peer reviewed journal.

PROJECT GOAL 3 To develop, translate, and broadly disseminate research findings as curriculum products on providing affirming care for LGBTQ persons to academic, clinical, and advocacy organizations through traditional and non-traditional venues.

METHODOLOGY » Research findings will be translated into medical education curriculum recommendations on addressing the primary health care needs for affirming care among LGBTQ patients. » Evidence-based affirming care curriculum will be developed in conjunction with national partners. » Curricular units will be mapped to the Medbiquitous Curriculum Inventory Working Group Standardized Instructional and Assessment Methods and Resource Types.

ANTICIPATED PRODUCTS » Data driven recommendations will be disseminated through a minimum of one scholarly presentation on the extent to which health care providers at community health centers are providing affirming care to LGBTQ patients and barriers to practice. » A minimum of one article will be published in a peer-reviewed journal on curriculum recommendations for teaching medical students to provide affirming care for LGBTQ patients. » Social media will be used to broadly disseminate research findings and curriculum products in providing affirming care for LGBTG patients » A policy brief with recommendations about the role of medical schools in training students and residents about affirming care will be developed and disseminated. » Technical assistance will be provided to other medical schools and residency programs on how to integrate affirming care for LGBTQ patients into their curriculum.

POLICY RELEVANCE Affirming care has been identified as an emerging area which has not received much attention in medical education or residency training resulting in a workforce that is ill-prepared to provide culturally appropriate care for the LGBTQ population. The lack of provision of culturally competent care for persons who are LGBTQ contributes to the continuing disparities in health access and outcomes for this population.

LIMITATIONS » Medical schools and residency programs may be resistant to additional curriculum demands » Medical schools and residency programs may not prioritize teaching students and residents about affirming care for LGBTQ patients.

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REFERENCES 1. Association AP. Diagnostic and statival manual of mental disorders. Arlington, VA, 2013. 2. Eriksson SES, Safer JD. Evidence-based curricular content improves student knowledge and changes attitudes towards transgender medicine. Endocrine Practice. 2016;22(7):837-841. 3. Fraser L, Knudson G. Education Needs of Providers of Transgender Population. Endocrinology and Metabolism Clinics of North America. 2019;48(2):465-477. 4. Department of Health and Human Services. 42 CFR Parts 412 and 495 [CMS-3310-FC and CMS-3311-FC], RINs 0938-AS26 and 0938-AS58. Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 3 and Modifications to Meaningful Use in 2015 through 2017. In: Department of Health and Human Services CfMaMS, edOctober 6, 2015. 5. Vance SR, Deutsch MB, Rosenthal SM, Buckelew SM. Enhancing Pediatric Trainees’ and Students’ Knowledge in Providing Care to Transgender Youth. Journal of Adolescent Health. 2017;60(4):425-430. 6. Reisner SL, Bradford, J., Hopwood, R. et al. Comprehensive Transgender healthcare: the affirming clinical and public health model of Fenway Health. Journal of Urban Health. 2015;92(3):584-592. 7. Liang JJ, Gardner IH, Walker JA, Safer JD. Observed deficiencies in medical student knowledge of transgender and intersex health. Endocrine Practice. 2017;23(8):897-906.

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8. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender–related content in undergraduate medical education. JAMA. 2011;306(9):971-977. 9. Dubin SN, Nolan IT, Streed CG, Jr., Greene RE, Radix AE, Morrison SD. Transgender health care: improving medical students’ and residents’ training and awareness. Adv Med Educ Pract. 2018;9:377-391. 10. Davidge-Pitts C, Nippoldt TB, Danoff A, Radziejewski L, Natt N. Transgender health in endocrinology: Current status of endocrinology fellowship programs and practicing clinicians. Journal of Clinical Endocrinology and Metabolism. 2017;102(4):1286-1290. 11. Hirschtritt ME, Noy G, Haller E, Forstein M. LGBT-specific education in general psychiatry residency programs: a survey of program directors. Academic Psychiatry. 2019;43(1):41-45. 12. Schechter LS, Cohen M. Gender Confirmation Surgery: A new frontier in plastic surgery education. Plastic and Reconstructive Surgery. 2016;138(4):784e-785e. 13. Dubin SN, Nolan IT, Streed Jr CG, Greene RE, Radix AE, Morrison SD. Transgender health care: improving medical students’ and residents’ training and awareness. Advances in medical education and practice. 2018;9:377.

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Year 4 Research Projects

YEAR 4 RESEARCH TOPIC

Addressing Immunization Disparities among Vulnerable Populations PI: Patricia Matthews-Juarez, PhD, pmatthews-juarez@mmc.edu (615) 327-6526 Contact person: Paul D. Juarez, PhD, pjuarez@mmc.edu (615) 327-6992 Date funded: UH1HP30348/ 07/01/2016 – 06/30/2021

PROJECT SUMMARY PROJECT DESCRIPTION: This research project will assess the extent to which medical schools prepare students to address the immunization disparities experienced by vulnerable populations in primary care settings. It will employ multiple methods to assess current medical school educational practice, identify evidence-based best practices, develop and recommend curricular modifications, and disseminate information to the broader medical education profession through presentations, policy briefs, peer reviewed journals, and social media.

STATEMENT OF THE PROBLEM: Physicians play a primary role in vaccination of the population. Yet, there are many barriers encountered to improving immunization rates. Common barriers to improved immunization rates include a lack of community demand for vaccination, poor patient access to vaccinations, and widespread myths about vaccinations leading to vaccine hesitancy. Lack of physician knowledge of vaccine recommendations, complex vaccination schedules, arbitrary state laws, and limited use of electronic records and tools, and poor communication also create barriers to improved immunization rates. Additionally, the lack of regular assessment of vaccine status, poor tracking of immunizations, provider financial incentives to vaccinate, and missed opportunities lead to less than optimal vaccination rates. Perhaps one of the biggest barriers to improved vaccination rates is poor clinician communication, especially with vaccine-hesitant patients. Poor communication regarding what to say when recommending vaccines and how to recommend vaccines reduces immunization rates. This research project will assess whether medical students are taught about the challenges encountered by vulnerable populations in obtaining recommended immunizations across the life course and how this can best be accomplished in primary care settings. (See Attachment for list of immunization schedules for children, adolescents, and adults).

RESEARCH QUESTIONS OR HYPOTHESIS: 1. What is the evidence base regarding education of medical students knowledge and awareness of immunization disparities experienced by vulnerable populations in primary care settings? 2. What are the core elements of the medical education curriculum that can be revised and adapted to ensure students have the knowledge and skills to provide culturally competent health care for vulnerable populations who present with immunization disparities?

PROJECT GOALS: » To work with our national partners to identify how and the extent to which patients at community health centers address immunization disparities among vulnerable patient groups, including LGBTQ, persons experiencing homelessness, and migrant farm workers. » To develop and map curricular elements that can be used by other medical schools to prepare students to ensure vulnerable populations have access to all recommended immunizations. » To disseminate research results on how medical schools can prepare students to address immunization disparities found among vulnerable populations.

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RESEARCH DESCRIPTION TITLE: Addressing Immunization Disparities Among Vulnerable Populations

STATEMENT OF THE PROBLEM. Disparities in health care access and quality create barriers for vulnerable populations that increase risk for adverse health outcomes. The Advisory Committee on Immunization Practices (ACIP) has designed a vaccination schedule to protect young children, teens, and adults before they are likely to be exposed to potentially serious diseases and when they are most vulnerable to serious infections. Unique circumstances and barriers encountered by persons who are lesbian, gay, bisexual, transgender and questioning (LGBTQ), homeless, and/or migrant farmworkers may decrease their likelihood of completing the schedule of childhood and adult vaccines, increasing their risk of infectious disease and of infecting others.

PROJECT DESCRIPTION AND POLICY RELEVANCE. The purpose of this study is to identify whether and/or how medical students are being taught to recognize and address the challenges and barriers encountered by vulnerable populations in completing the schedule of childhood and adult immunizations. This research project will assess the extent to which medical schools prepare students to understand and address the needs of vulnerable populations in obtaining vaccinations in primary care settings. It will employ multiple methods to assess current medical school educational practice, identify evidence-based best practices, identify, develop and recommend curricular modules, and disseminate information to the broader medical education profession through presentations at professional meetings, policy briefs, publication of articles, and through social media. Persons experiencing homelessness, or are LGBTQ or migrant farm workers are at higher risk for morbidity and mortality from both chronic and episodic illness than the general population. Few data are available on the prevalence of these conditions among vulnerable populations or the uptake or completion of vaccinations for prevention. The overall aim of this research project is to increase knowledge about the unique conditions and circumstances encountered by each of these three vulnerable populations to completing the recommended childhood and adult vaccination schedules in order to prevent them and people they come into contact with from risk for contracting infectious, yet preventable diseases.

TARGET POPULATIONS » LGBTQ persons » Persons experiencing homelessness » Migrant farmworkers

RESEARCH QUESTIONS OR HYPOTHESIS: » What is the evidence base regarding education of medical students being trained to meet the unique immunization challenges experienced by vulnerable populations? » How effective are community health centers in providing recommended immunizations to persons who are LGBTQ, experiencing homelessness or migrant farmworkers? » What are the core elements of the medical educational curriculum that can be revised and adapted to ensure students have the knowledge and skills to provide culturally competent health care for vulnerable populations who need age specific immunizations?

PROJECT GOALS: » To conduct a survey in collaboration with national partners to identify the extent to which medical students are trained to address immunization disparities experienced by persons who identify as LGBTQ, are migrant farm workers, or experiencing homelessness. » To develop model curricular elements that can be used by other medical schools to prepare students to more effectively address immunization disparities among vulnerable populations. » To broadly disseminate research findings and curriculum recommendations on how medical schools can better address immunization disparities found among vulnerable populations through both traditional and non-traditional venues.

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WORK PLAN PROJECT GOAL 1: To conduct a survey in collaboration with national partners to assess the extent to which patients at community health centers who are LGBTQ, experiencing homelessness, or are migrant farmworkers receive recommended immunizations and barriers to receiving them.

METHODOLOGY » We will work with our consultants, the Fenway Institute, the Migrant Clinicians Network, and the National Health Care for the Homeless Council to develop and administer a survey to assess the extent to which health care providers seek to ensure that vulnerable populations have CDC recommended immunizations across the life course and to identify barriers to success. » A sample of medical records of the target population will be completed to assess the extent to which it can be determined that patients are up to date with immunizaitons. » A cross-sectional survey will be administered to staff of community health centers to identify how they address immunization disparities among vulnerable populations and barriers to providing them.

ANALYSIS » Mohammad Tabatabai, PhD, statistician and co-investigator will lead the data analysis efforts.

ANTICIPATED PRODUCT » A minimum of one presentation will be made on how community health centers are addressing immunization disparities among vulnerable populations in primary care settings and barriers to care. » A minimum of one scholarly presentation will be submitted to a peer reviewed journal on how community health centers are addressing immunization disparities among vulnerable populations in primary care settings and the barriers to care.

PROJECT GOAL 2: To develop model curricular elements that can be used by medical schools to prepare students to effectively address immunization disparities among health care for vulnerable populations.

METHODOLOGY » A systematic review of the literature will be completed to identify best practices in medical education in teaching students to address immunization disparities among vulnerable populations. » Monthly video-conferences with CoP members and national partners will be conducted to develop the framework for designing curriculum to teach students to identify and respond to immunization disparities encountered by vulnerable populations.

ANTICIPATED PRODUCT » A policy brief and other scholarly products will be disseminated to medical education professionals on how medical schools are addressing immunization disparities in their curricula; » The immunization curriculum modules will be finalized and disseminated to other medical school and residency training programs. » Technical assistance will be provided to other medical schools on how to modify their curriculum to better address immunization disparities experienced by vulnerable populations.

LIMITATIONS » Medical schools may be resistant to additional curriculum demands » Medical schools may not prioritize teaching students and residents about immunization disparities experienced by vulnerable populations.

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PROJECT GOAL 3: To broadly disseminate research findings and curriculum products for addressing immunization disparities to academic, clinical, and advocacy organizations.

METHODOLOGY » Curricular units will be mapped to the Medbiquitous Curriculum Inventory Working Group Standardized Instructional and Assessment Methods and Resource Types. » Research findings and curriculum products will be disseminated through presentations to both professional and community organizations. » Social media will be used to broadly disseminate research findings and curriculum products in addressing immunization disparities among vulnerable populations.

ANTICIPATED PRODUCTS » A minimum one article for publication will be published in a peer reviewed journal on curriculum recommendations to better prepare medical students to address immunization disparities among vulnerable populations across the life course. » Policy briefs on inclusion of addressing immunization disparities among vulnerable populations will be submitted to a minimum of eight national and regional medical education and health professions organizations.

LIMITATIONS » Medical schools and residency programs may be resistant to additional curriculum demands » Medical schools may not prioritize teaching students and residents about immunization disparities among vulnerable population.

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Year 4 Research Projects

REFERENCES: Aldridge, R. W., Hayward, A. C., Hemming, S., Yates, S. K., Ferenando, G., Possas, L., . . . Story, A. (2018). High prevalence of latent tuberculosis and bloodborne virus infection in a homeless population. Thorax, 73(6), 557. Alexander, A. B., Best, C., Stupiansky, N., & Zimet, G. D. (2015). A model of health care provider decision making about HPV vaccination in adolescent males. Vaccine, 33(33), 4081-4086. doi:https://doi. org/10.1016/j.vaccine.2015.06.085 Bednarczyk, R. A., Whitehead, J. L., & Stephenson, R. (2017). Moving beyond sex: Assessing the impact of gender identity on human papillomavirus vaccine recommendations and uptake among a national sample of rural-residing LGBT young adults. Papillomavirus Research, 3, 121-125. doi:https://doi.org/10.1016/j.pvr.2017.04.002 Beijer, U., Wolf, A., & Fazel, S. (2012). Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: a systematic review and meta-analysis. The Lancet infectious diseases, 12(11), 859-870. doi:10.1016/S1473-3099(12)70177-9 Cahill S1, Makadon H3,4. (2014). Sexual Orientation and Gender Identity Data Collection in Clinical Settings and in Electronic Health Records: A Key to Ending LGBT Health Disparities. LGBT Health., 1(1), 34-41. Cassone, A. (2012). Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: a systematic review and meta-analysis. Pathogens and Global Health, 106(7), 377-377. doi:10.1179/204777241 2Z.00000000086 Fierman, A. H., Dreyer, B. P., Acker, P. J., & Legano, L. (1993). Status of Immunization and Iron Nutrition in New York City Homeless Children. Clinical Pediatrics, 32(3), 151-155. doi:10.1177/000992289303200305 Fontenot, H. B., Lee-St. John, T., Vetters, R., Funk, D., Grasso, C., & Mayer, K. H. (2016). The Association of Health Seeking Behaviors With Human Papillomavirus Vaccination Status Among High-Risk Urban Youth. Sexually Transmitted Diseases, 43(12), 771-777. doi:10.1097/ olq.0000000000000521 Gray, G. C., & Kayali, G. (2009). Facing pandemic influenza threats: The importance of including poultry and swine workers in preparedness plans1. Poultry Science, 88(4), 880-884. doi:10.3382/ps.2008-00335

Hurley, L. P., Lindley, M. C., Harpaz, R., & et al. (2010). BArriers to the use of herpes zoster vaccine. Annals of Internal Medicine, 152(9), 555-560. doi:10.7326/0003-4819-152-9-201005040-00005 Hutchins, S. S., Truman, B. I., Merlin, T. L., & Redd, S. C. (2009). Protecting Vulnerable Populations From Pandemic Influenza in the United States: A Strategic Imperative. American Journal of Public Health, 99(Suppl 2), S243-S248. doi:10.2105/AJPH.2009.164814 Jones, J., Poole, A., Lasley-Bibbs, V., & Johnson, M. (2016). LGBT health and vaccinations: Findings from a community health survey of Lexington-Fayette County, Kentucky, USA. Vaccine, 34(16), 1909-1914. doi:https://doi.org/10.1016/j.vaccine.2016.02.054 Kaplan-Weisman, L., Waltermaurer, E., & Crump, C. (2018). Assessing and Improving Zoster Vaccine Uptake in a Homeless Population. Journal of community health. doi:10.1007/s10900-018-0517-x Kemsley, M., & Riegle, E. A. (2004). A Community-campus Partnership: Influenza Prevention Campaign. Nurse Educator, 29(3), 126-129. Lee, C. V., McDermott, S. W., & Elliott, C. (1990). The delayed immunization of children of migrant farm workers in South Carolina. Public Health Reports, 105(3), 317-320. McRee, A.-L., Katz, M. L., Paskett, E. D., & Reiter, P. L. (2014). HPV vaccination among lesbian and bisexual women: Findings from a national survey of young adults. Vaccine, 32(37), 4736-4742. doi:https://doi.org/10.1016/j.vaccine.2014.07.001 Schoch-Spana M1, B. N., Rambhia KJ, Norwood A. (2010). Stigma, health disparities, and the 2009 H1N1 influenza pandemic: how to protect Latino farmworkers in future health emergencies. Biosecur Bioterror., 8(3), 243-254. Steege, A. L., Baron, S., Davis, S., Torres-Kilgore, J., & Sweeney, M. H. (2009). Pandemic Influenza and Farmworkers: The Effects of Employment, Social, and Economic Factors. American Journal of Public Health, 99(Suppl 2), S308-S315. doi:10.2105/AJPH.2009.161091 Young, S., Dosani, N., Whisler, A., & Hwang, S. (2014). Influenza Vaccination Rates Among Homeless Adults With Mental Illness in Toronto. Journal of Primary Care & Community Health, 6(3), 211-214. doi:10.1177/2150131914558881

Hurley, L. P., Bridges, C. B., Harpaz, R., Allison, M. A., O’Leary, S. T., Crane, L. A., . . . Kempe, A. (2014). U.S. Physicians’ Perspective of Adult Vaccine Delivery. Annals of Internal Medicine, 160(3), 161-161. doi:10.7326/M132332 Hurley, L. P., Lindley, M. C., Allison, M. A., Crane, L. A., Brtnikova, M., Beaty, B. L., . . . Kempe, A. (2017). Financial Issues and Adult Immunization: Medicare Coverage and the Affordable Care Act. Vaccine, 35(4), 647-654. doi:10.1016/j.vaccine.2016.12.007

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YEAR 4 POLICY BRIEF

Transforming Medical Education to Provide Gender Affirming Care (GAC) for Transgender Patients WHO THE POLICY BRIEF IS AIMED AT? » Curriculum planners in medical schools (undergraduate and graduate medical education programs), medical school faculty and academicians » Education policy makers in government and advisory bodies (Health Resources Services Administration-HRSA; National Institutes of Health-NIH; American Association of Medical Colleges-AAMC; Liaison Committee on Medical Education- LCME; Southern Association of Colleges and Schools-SACS; Council on Education for Public Health- CEPH; National Medical Association- NMA; American Medical Association-AMA and medical societies)

KEY MESSAGES » The Gender Affirming Care (GAC) policy brief could provide information on how to access learning resources for trainees, educators and patients. » The GAC policy brief can help government organizations, care providers, and facilities to adopt and popularize the recommendations. » This GAC policy brief can contribute to policy-making for provision of high-quality care to gender and sexual minorities (GSM). » This policy brief also calls for ensuring that healthcare professionals’ practice cultural humility in addressing the health issues of GSM towards achieving health equity.

POLICY OPTIONS » Evaluation of existing information on GAC training should be considered prior to proposing and accepting the existing curricular interventions. » Multidisciplinary engagement of stakeholders (general public, patients/consumers, patient advocates, community advocacy groups and care providers) is necessary to develop the objectives before policy making at government, healthcare system, and medical school levels.

POLICY RELEVANCE Transgender health care has been identified as an emerging area that has not received adequate attention in medical education or residency training resulting in a workforce that is ill-prepared to provide culturally appropriate care for this population.

EXECUTIVE SUMMARY Medical students and residents lack appropriate and sufficient training on how to provide gender-affirming and inclusive care to transgender patients and other vulnerable groups having gender-related issues. The proposed policy brief advocates for equipping medical students and residents with knowledge and skills to provide culturally competent care. It is expected that the curricular interventions on GAC will result in perceived and quantifiable improvements in transgender patient care.

INTRODUCTION/STATEMENT OF THE PROBLEM Transgender people have a gender identity that differs from their assigned sex at birth.1 Because transgender medicine is not adequately covered in medical curricula, few care providers are comfortable with providing care, including gender affirming care to transgender patients.2,3 While there has been an increasing call for medical schools to ensure students are trained to provide culturally appropriate care for Lesbian, Gay, Bisexual, Transgender, Queer and/or Questioning (LGBTQ) patients, there is a lacuna in provision of gender affirming care to future health care providers in medical school education and residency training programs.4-6 A 2009-2010 survey administered to medical school deans about LGBTQ-related content in medical education found that the median reported time dedicated to LGBTQ-related topics was small (e.g., approximately or average 5 hours) and that the dedicated amount of time, covered content, and perceived quality of instruction varied substantially.7 There is an increasing number of medical residency specialty and sub¬specialty programs, including OB/GYN, Endocrinology, Urology, Surgery and Psychiatry that have identified the need for residents to receive training in gender affirming care for transgender patients7-11. However, medical education curriculum time and materials tends to focus on medical management of gender-affirming hormones which are typically beyond the scope of the general primary care provider and lack primary care considerations. Little curriculum time of medical schools currently is allotted to addressing the unique, gender affirming, primary care needs of transgender patients.8

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METHODS/APPROACHES In order to identify and assess how medical students and residents are being trained to provide gender affirming care to transgender patients, we have conducted a systematic review of literature from 2000 until 2020. We used PRISMA guidelines12 to identify original studies that focused on medical school training to increase knowledge and comfort, as well as improve the attitudes and skills of medical students and residents working with GSM patients. Our search included the databases such as Google Scholar, PubMed, OVID, ERIC, SCOPUS, Web of Science, CINAHL, PsychInfo, and MedEdPortal. The search strategy cross-referenced keywords for transgender populations (transgender, gender identity, transsexual, gender reassignment, gender affirmation, gender queer, gender nonconforming, gender dysphoria, transgender non-conforming/TGNC) with keywords for medical students and residents (medical student, medical resident), and medical education (medical school curriculum, basic science, clinical, rotations, OSCE, standardized patient). Data extraction from the articles focused on criteria such as study description, study design, educational intervention etc. Study quality was evaluated by a committee of authors using published recommendations.13

RESULTS Out of a total of 21059 articles screened and subjected to various inclusion and exclusion criteria, and full text review, 32 articles were identified that had educational intervention component and focused on medical students and/or residents. Study quality over all was low to moderate and limited to quasi and pre-experimental designs. The majority of the studies focused on medical student training, and few included residents. The educational/training methods described included didactic sessions, patient panels, standardized patients, small group discussions, and student-delivered presentations. Overall, combining a variety of training methods appears to hold more promise in affirming/inclusive care training at the undergraduate medical education (UME) level.

LIMITATIONS/CHALLENGES » Medical schools and residency programs may be resistant to additional curriculum demands. » There is a dearth of evaluation of training approaches that use longer term assessments of attitude, comfort, and belief changes in students and residents. » Measures to assess competency (e.g., objective structured clinical examinations [OSCEs] and practice observations) are lacking in the studies that were reviewed. » There is a greater need for graduate medical education (GME) training in affirming care. » There were no articles addressing training in affirming care regarding other vulnerable populations, which include migrant farm workers or individuals experiencing homelessness.

POLICY RECOMMENDATIONS » Standardize measures to assess learning outcomes regarding affirming and inclusive care. » Develop curriculum modules on “Affirming Care” and plot test these modules in medical schools. » Engage transgender people with legal, health care, finance, social work and community engagement backgrounds as part of clinical network & working groups. » Monitor health outcomes of transgender patients to assess the quality of care received both in outpatient and inpatient care settings. » Encourage experienced clinicians to mentor less experienced students and clinicians (during clerkship, residency and early years of practice) in transgender healthcare. » Emphasize privacy, confidentiality, and cultural humility in healthcare settings providing care to transgender patients. » Emphasize importance of creating welcoming environment to eliminate micro/macroaggression and other actions resulting from implicit bias and transphobia.

ACKNOWLEDGMENTS This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UH1HP30348, entitled academic Units for Primary Care Training and Enhancement. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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SOURCES 1. Diagnostic and Statistical Manual of Mental Disorders, 5th Addition: DSM-5. Arlington, VA, 2013. 2. Eriksson SES, Safer JD. Evidence-based curricular content improves student knowledge and changes attitudes towards transgender medicine. Endocrine Practice. 2016;22(7):837-841. 3. Fraser L, Knudson G. Education Needs of Providers of Transgender Population. Endocrinology and Metabolism Clinics of North America. 2019;48(2):465-477. 4. Vance SR, Deutsch MB, Rosenthal SM, Buckelew SM. Enhancing Pediatric Trainees' and Students' Knowledge in Providing Care to Transgender Youth. Journal of Adolescent Health. 2017;60(4):425430. 5. Reisner SL, Bradford, J., Hopwood, R. et al. Comprehensive Transgender Healthcare: The Gender Affirming Clinical and Public Health Model of Fenway Health. Journal of Urban Health. 2015;92(3):584-592. 6. Liang JJ, Gardner IH, Walker JA, Safer JD. Observed deficiencies in medical student knowledge of transgender and intersex health. Endocrine Practice. 2017;23(8):897-906. 7. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender–related content in undergraduate medical education. JAMA. 2011;306(9):971-977.

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8. Dubin SN, Nolan IT, Streed CG, Jr., Greene RE, Radix AE, Morrison SD. Transgender health care: improving medical students' and residents' training and awareness. Adv Med Educ Pract. 2018;9: 377-391. 9. Davidge-Pitts C, Nippoldt TB, Danoff A, Radziejewski L, Natt N. Transgender health in endocrinology: Current status of endocrinology fellowship programs and practicing clinicians. Journal of Clinical Endocrinology and Metabolism. 2017;102(4):1286-1290. 10. Hirschtritt ME, Noy G, Haller E, Forstein M. LGBT-Specific Education in General Psychiatry Residency Programs: a Survey of Program Directors. Academic Psychiatry. 2019;43(1):41-45. 11. Schechter LS, Cohen M. Gender Confirmation Surgery: A New Frontier in Plastic Surgery Education. Plastic and Reconstructive Surgery. 2016;138(4):784e-785e. 12. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009 Oct;62(10):1006-12. 13. Hammick M, Dornan T, Steinert Y. Conducting a best evidence systematic review. Part 1: from idea to data coding. BEME Guide No. 13. Med Teach. 2010 Jan;32(1):3-15.

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YEAR 4 POLICY BRIEF

Opportunities for Addressing Immunization Disparities in Medical Professions Training WHO THE POLICY BRIEF IS AIMED AT? » Curriculum planners in medical schools » Education policy makers in government and advisory bodies (Health Resources Services Administration, National Institutes of Health, Association American Medical Colleges, Liaison Committee on Medical Education, Southern Association of Colleges and Schools, Council on Education for Public Health, National Medical Association and medical societies)

KEY MESSAGES » This immunization disparity training policy brief provides guidance on how to improve training for medical students and residents to increase immunization rates and decrease immunization hesitancy. » Immunization disparity training helps government, care providers, educators and facilities to adopt and popularize the recommendations. » Immunization disparity training policy brief contributes to policy making in regard to providing equal access to high quality care. » This policy brief also calls for ensuring that healthcare professionals’ practice cultural humility, particularly with vulnerable populations, in addressing the health issues towards achieving health equity.

POLICY OPTIONS » Existing information on immunization disparity training should be considered and evaluated before proposing and accepting curricular interventions. » Multidisciplinary engagement of stakeholders (general public, patients/consumers, community advocacy groups and care providers) is necessary to develop agreed upon training objectives before policy making.

POLICY RELEVANCE Health care for vulnerable populations regarding immunization disparities has been identified as an emerging area which has not received adequate attention in medical education or residency training resulting in a workforce that is ill-prepared to provide culturally responsive and appropriate care for these populations.

EXECUTIVE SUMMARY Medical students and residents currently lack appropriate and adequate training to provide address immunizations and immunization hesitancy. This lack is even more pronounced when considering vulnerable populations such as gender and sexual minorities, persons experiencing homelessness and migrant farm workers. This policy brief advocates for equipping students and residents with knowledge and skills to address vaccine hesitancy and decrease immunization disparities. It is expected that curricular interventions will result in perceived and quantifiable improvements in patient care for vulnerable populations.1

INTRODUCTION/STATEMENT OF THE PROBLEM The topic of immunization is a critical issue at this time due to the availability of the SARS-CoV-2 vaccine, and the high levels of vaccine hesitancy.2 Vaccines have been shown to be an effective method to reduce the the transmission of disease, however, they are often underutilized.3-5 Lack of confidence in vaccine efficacy, concerns about side effects are two factors that have led to non-compliance with vaccine recommendations.1 These factors are often compounded among vulnerable populations due to general medical mistrust, lack of insurance, and/or lack of knowledge regarding availability.6 In recent years the number of vaccine-preventable illness outbreaks have increased.7 There is an increasing number of healthcare providers that are non-compliant with vaccinations, potentially lowering the public trust in these vaccinations.8 Currently, little curriculum time in medical school is allotted to addressing immunization disparities and ways to address the needs of vulnerable populations when it comes to receiving immunizations.9,10

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METHODS/APPROACHES In order to identify effective training methods for medical professionals to decrease disparities among vaccine recipients, we conducted a systematic review of literature from 1990 until 2020. We used PRISMA guidelines to identify original studies that focused on improving knowledge surrounding vaccines. Our search included 7 databases, including Google Scholar, PubMed, OVID, ERIC, Web of Science, CINAHL, and MedEd Portal. The search strategy cross referenced keywords for immunizations (immunization, vaccinations) with keywords for medical training (medical students, residents, medical education, curriculum). Data extraction from the articles focused on criteria such as study description, study design, educational intervention etc. Study quality was evaluated by authors using published recommendations.

RESULTS Out of a total of 1,266 articles screened, subjected to various inclusion and exclusion criteria, and full text review, 20 articles were identified that reported on an educational intervention and focused on medical students and residents. Study quality overall was moderate with mainly quasi and pre-experimental designs. Training intervantions for medical students were the most common focus of study (12 articles); followed by residents (4); a combination of students and residents; (2) and students and faculty (2). Interventions used included didactic sessions, patient panels, standardized patients, simulated patient encounters, small-group discussions, and student led presentations. Overwhelmingly, interventions increased knowledge about immunizations, as well as changing beliefs and attitudes related to vaccination and improving patient communication regarding vaccines and related hesitancy.

LIMITATIONS/CHALLENGES » Lack of causality between educational interventions and vaccination outcomes » Disparities were not addressed using a social vulnerabilities perspective » None of the studies focused on vulnerable populations (LGBTQ+, people experiencing homelessness, and migrant farm workers)

POLICY RECOMMENDATIONS » Standardize measures to assess learning outcomes regarding immunization knowledge, attitudes, and beliefs. » Develop curriculum modules on immunization knowledge and pilot test these modules in medical schools and during residency. » Engage people with legal, health care, finance, social work and community engagement backgrounds as part of clinical networks and working groups. » Monitor health outcomes of patients as well as healthcare provider behaviros to assess the quality of care received both in outpatient and inpatient care settings. » Encourage experienced clinicians multiple years experience post residency to mentor less experienced students and clinicians (during clerkship, residency and early years of practice) in immunization knowledge and misconceptions. » Establish privacy, confidentiality, and cultural humility guidelines in patient care settings. » Consider childhood immunization in combination with COVID-19 vaccinations, minding the suggested time frames between COVID-19 vaccination and other immunizations.

ACKNOWLEDGMENTS This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UH1HP30348, entitled academic Units for Primary Care Training and Enhancement. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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SOURCES 1. Heininger U: An internet-based survey on parental attitudes towards immunization. Vaccine 2006, 24:6351-6355 2. Dror AA, Eisenbach N, Taiber S, Morosov NG, Misrachi M, Zigron A, Srouji S, Sela E. Vaccine hesitancy: the next challenge in the fight agains COVID-19. European Journal of Epidemiology. 2020; 35:775-779. 3. Centers for Disease Control and Prevention: Influenza vaccination coverage among children with asthma - United States, 20042005 influenza season. MMWR 2007, 56:193-196. 4. Skull SA, Andrews RM, Byrnes GB, Kelly HA, Nolan TM, Brown GA, Campbell DA: Missed opportunities to vaccinate a cohort of hospitalized elderly with pneumococcal and influenza vaccines. Vaccine 2007, 25:5146-5154. 5. Gust DA, Strine TW, Maurice E, Smith P, Yusef H, Wilkinson M, Battaglia M, Wright R, Schwartz : Under-immunization among children: effects on vaccine safety concerns on immunization status. Pediatrics 2004, 114: e16-e22. 6. Bogart LM, Ojikutu BO, Tyagi K, Klein DJ, Mutchler MG… COVID-19 related medical mistrust, health impacts, and potential vaccine hesitance among Black Americans lving with HIV. J Acquir Immune Defic Syndr. 2021; 1:86: 200-207.

7. Salmon DA, Dudley MZ, Glanz JM, Omer SB. Vaccine hesitancy: causes, consequences, and a call to action. Am J Prev Med. 2015;49(6)(suppl 4):S391-S398. http://dx.doi.org/10.1016/j. amepre.2015.06.009 8. Walker F, Singleton J, Lu P, Strikas R: Influenza vaccination of healthcare workers in the United States, 1989-1997. Infect Control Hosp Epidemiol 2000, 21:113. 9. Kerneis S, Jacquet C, Bannay A, May T, Launay O, Verger P, et al. Vaccine education of medical students: a nationwide crosssectional survey. Am J Prev Med 2017;53:E97–E104. 10.1016/ j.amepre.2017.01.014. [PubMed: 28237636] 10. Henrikson NB, Opel DJ, Grothaus L, Nelson J, Scrol A, Dunn J, et al. Physician communication training and parental vaccine hesitancy: a randomized trial. Pediatrics 2015;136:70–9. 10.1542/ peds.2014-3199. [PubMed: 26034240]

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YEAR 5 RESEARCH TOPIC

Transforming Medical Education to Address Mental Health Disparities among Vulnerable Populations PI: Patricia Matthews-Juarez, PhD, pmatthews-juarez@mmc.edu (615) 327-6526 Contact person: Paul D. Juarez, PhD, pjuarez@mmc.edu (615) 327-6992 Date funded: UH1HP30348/ 07/01/2016 – 06/30/2021

PROJECT SUMMARY Project Description: This research project will assess the extent to which medical schools prepare students to address the mental health of vulnerable populations in primary care settings. It will employ multiple methods to assess current medical school educational practice, identify evidence-based best practices, develop and recommend curricular modifications, and disseminate information to the broader medical education profession through presentations at professional meetings, policy briefs, and articles in peer reviewed journals. Statement of the Problem: Screening conducted by primary care providers (PCPs) for mental health conditions and substance use disorders can enhance early detection and treatment, which has the potential to improve patient health outcomes and lower health care costs (1). PCPs increasingly serve a critical role as a first point of contact for patients who could benefit from mental health care. For example, it is estimated that depression and substance use disorders account for 10% and 20%, respectively, of all primary care visits (2,3). The U.S. Preventive Services Task Force and other national medical organizations recommend that PCPs screen all adults for mood and alcohol/substance use disorders (4). However, screening rates for mental health conditions in primary care settings remain low (5). One important factor driving low screening rates is inadequate training (6). There currently is limited evidence regarding best practices for teaching medical students how to screen for and address mental health conditions among vulnerable populations. It is important that medical students are prepared to identify risk and protective factors relevant for prevention among vulnerable patient groups, assess symptoms required for psychiatric diagnosis, and to provide treatment referrals and conduct follow-up assessments when necessary. This research project will assess whether medical students are taught about the mental health of vulnerable populations and the degree to which they receive training relevant for screening, care, and treatment referrals in primary care settings.

RESEARCH QUESTIONS OR HYPOTHESIS: » What is the evidence regarding education of medical student’s knowledge and awareness of immunization disparities experienced by vulnerable populations in primary care settings? » What are the core elements of the medical education curriculum that can be revised and adapted to ensure students have the knowledge and skills to provide culturally competent health care for vulnerable populations who present with immunization disparities?

PROJECT GOALS: » To identify the extent to which medical students are trained to address immunization disparities among vulnerable patient groups. » To develop model curricular elements that can be used by other medical schools to prepare students to effectively screen for and ensure vulnerable populations have current immunizations. » To disseminate research results on how medical schools are addressing immunization disparities among vulnerable populations.

RESEARCH DESCRIPTION TITLE Transforming Medical Education to Address Mental Health Disparities Among Vulnerable Populations

STATEMENT OF THE PROBLEM Screening conducted by primary care providers (PCPs) for mental health conditions and substance use disorders can enhance early detection and treatment, which has the potential to improve patient health outcomes and lower health care costs (1). PCPs increasingly serve a critical role as a first point of contact for patients who could benefit from mental health care. For example, it is

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estimated that depression and substance use disorders account for 10% and 20%, respectively, of all primary care visits (2,3). The U.S. Preventive Services Task Force and other national medical organizations recommend that PCPs screen all adults for mood and alcohol/substance use disorders (4). However, screening rates for mental health conditions in primary care settings remain low (5). One important factor driving low screening rates is inadequate training (6). There currently is limited evidence regarding best practices for teaching medical students how to screen for and address mental health conditions among vulnerable populations. It is important that medical students are prepared to identify risk and protective factors relevant for prevention among vulnerable patient groups, assess symptoms required for psychiatric diagnosis, and to provide treatment referrals and conduct follow-up assessments when necessary. This research project will assess whether medical students are taught about the mental health of vulnerable populations and the degree to which they receive training relevant for screening, care, and treatment referrals in primary care settings.

RESEARCH DESCRIPTION AND POLICY RELEVANCE The current healthcare workforce lacks sufficient training on the early detection of mental health and substance use disorders among vulnerable populations. Screening for mental health conditions in primary care settings can help to reduce health disparities among vulnerable patient populations by initiating interventions that can alter health trajectories. Academic health centers are strategically positioned to train medical students who will impact the health of vulnerable populations by educating future generations of providers, advancing science, and delivering integrated care that addresses the unique mental health care needs of these communities.

TARGET POPULATIONS Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals, persons experiencing homelessness, and migrant farmworkers are all at increased risk for mental health disorders due to a variety of factors, including increased exposure to stressful and traumatic life events, interpersonal and institutional discrimination, implicit provider biases, low levels of income and education, and lack of access to culturally competent health care providers. Despite efforts in the United States to reduce or eliminate disparities in health and healthcare in recent years, significant disparities related to mental health still remain. LGBTQ Persons. LGBTQ individuals experience higher rates of mental health problems compared to their heterosexual counterparts, including mood and anxiety disorders (7) as well as suicidal ideation and self-harm (8). This increased risk for psychopathology is due, in part, to higher exposures to stressful and traumatic life events (9). LGBTQ individuals are unlikely to disclose their sexual orientation and/or gender identity to their PCPs (10) due to concerns regarding biases, discrimination, and refusals to treat (11). Hence, training medical students to screen for mental health risk factors and disorders in LGBTQ patients must build on broader training in cultural competencies relevant for this population. Persons Experiencing Homelessness. Persons experiencing homelessness are at increased risk for mental health problems compared to the general population (12). Increased risk for mental illness in this population may be attributed to a variety of factors, including elevated exposure to stressful and traumatic life events (13), lack of insurance, and increased and biases encountered in health care settings (14). Migrant Farmworkers. Migrant farmworkers face increased risk compared to the general population for exposure to a variety of stressors, including discrimination, interpersonal violence, separation from family, long work hours, and fears of unemployment and underemployment (15,16). Exposure to these stressors, in turn, increases risk for developing mental illness and substance abuse (17). Mental health disparities affecting immigrant and ethnic minority groups are compounded by barriers to health care utilization, including health care professionals’ negative attitudes and behaviors (18). Taken together, these findings highlight the importance of training medical students to provide culturally competent mental health screening for LGBTQ individuals, persons experiencing homelessness, and migrant farmworkers. Improved screening has the potential to enhance early risk detection and mental health interventions to minimize mental health disparities in these vulnerable patient groups.

RESEARCH QUESTIONS OR HYPOTHESIS: » What is the evidence base regarding education of medical students on screening, assessment, and referral to treatment for mental health conditions among vulnerable populations in primary care settings? » What are the core elements of the medical educational curriculum that can be revised and adapted to ensure students have the knowledge and skills to provide culturally competent health care for vulnerable populations who present with mental health conditions?

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PROJECT GOALS: » To identify the extent to which medical students are trained in screening, assessment, and referral to treatment for mental health conditions among vulnerable patient groups. » To develop model curricular elements that can be used by other medical schools to prepare students to effectively provide mental health care for vulnerable populations. » To disseminate research results on how medical schools are addressing mental health care for vulnerable populations to a graduate medical education audience.

WORK PLAN PROJECT GOAL 1 To identify the extent to which medical students are trained in screening, assessment, and referral to treatment for mental health conditions among vulnerable patient groups.

METHODOLOGY » We will use PRISMA guidelines to conduct a systematic review of the literature from 2005 until present using Scopus, PubMed, Web of Science, EBSCOhost, Google Scholar and PsycINFO. A systematic review will be conducted according to PRISMA guidelines. The search strategy cross-referenced keywords for LGBTQ populations (lesbian, gay, bisexual, transgender, questioning, queer, homosexual, MSM, WSW, sexual minority) with keywords for health care providers (provider, physician, doctor, nurse, medical student, medical resident, health personnel, practitioner) and keywords for mental health (mental health, DSM, psychiatric, psychology, mental, depression, mood disorder, affective disorder, bipolar disorder, anxiety disorder, posttraumatic stress disorder, substance use disorder, substance abuse, substance dependence, psychotic disorder).

ANALYSIS » The systematic review of the literature on how medical school curricula address mental health in vulnerable populations will be analyzed using the PRISMA guidelines.

ANTICIPATED PRODUCT » We will disseminate evidence-based recommendations through a minimum of two scholarly presentations on how medical schools might structure their curriculum to better prepare students to address mental health among vulnerable populations in primary care settings. » We will disseminate evidence-based recommendations through a minimum of one publication through a peer reviewed publication on how medical schools might structure their curriculum to better prepare students to address mental health among vulnerable populations in primary care settings

PROJECT GOAL 2 To develop model curricular elements that can be used by other medical schools to prepare students to effectively provide mental health care for vulnerable populations.

METHODOLOGY » We will identify and maintain a repository of best practices in medical student education about screening and referral for mental health services among LGBTQ, persons experiencing homelessness, and migrant workers. » We will develop model medical education curricular modules on mental health, including a minimum of one patient simulation script. » We will map recommended curricular units to the Medbiquitous Curriculum Inventory Working Group Standardized Instructional and Assessment Methods and Resource Types.

ANALYSIS » Dr. Mohammad Tabatabai will conduct the analysis of survey responses from Offices of Graduate Medical Education at all 146 US medical schools. » Dr. Mohammad Tabatabai will analyze medical student surveys. Dr. Tabatabai is a biostatistician.

ANTICIPATED PRODUCT » We will establish a web-accessible repository of curricular modules on mental health care for vulnerable populations

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PROJECT GOAL 3 To disseminate research results on how medical schools are addressing mental health care for vulnerable populations to a graduate medical education audience.

METHODOLOGY » We will disseminate a policy brief with recommendations about the role of medical schools in training students and residents about the mental health of vulnerable populations. » We will identify and disseminate best practices in medical student education about screening of – and referral to treatment for - mental health conditions among LGBTQ, persons experiencing homelessness, and migrant workers through scholarly presentations and peer reviewed publications » We will identify and disseminate model curricular elements that can be used by other medical schools to prepare students to effectively address the mental health of vulnerable populations.

ANTICIPATED PRODUCT » We will disseminate a policy brief and scholarly products to medical education professionals on how medical schools are addressing the mental health of LGBTQ, homeless and migrant worker populations in their curricula; » We will provide technical assistance to other medical schools on how to modify their curriculum to better address the mental health of vulnerable populations.

LIMITATIONS » Anticipated limitations include incomplete survey response from both the Offices of Graduate Medical Education and students at the four HBCU medical schools. » Identification of specific literature and other evidence that define the specific topics included in the curriculum in medical education in medical schools.

REFERENCES 1. Talen, M. R., Baumer, J. G., & Mann, M. M. (2013). Screening measures in integrated behavioral health and primary care settings. In Integrated Behavioral Health in Primary Care (pp. 239-272). Springer, New York, NY. 2. Frank, R. G., Huskamp, H. A., & Pincus, H. A. (2003). Aligning incentives in the treatment of depression in primary care with evidence-based practice. Psychiatric Services, 54(5), 682-687. 3. Bradley, K. A. (1994). The primary care practitioner's role in the prevention and management of alcohol problems. Alcohol Health & Research World, 18(2), 97-105. 4. Siu, A. L., Bibbins-Domingo, K., Grossman, D. C., Baumann, L. C., Davidson, K. W., Ebell, M., ... & Krist, A. H. (2016). Screening for depression in adults: US Preventive Services Task Force recommendation statement. Jama, 315(4), 380-387. 5. Harrison, D. L., Miller, M. J., Schmitt, M. R., & Touchet, B. K. (2010). Variations in the probability of depression screening at community-based physician practice visits. Primary care companion to the Journal of clinical psychiatry, 12(5). 6. Mulvaney-Day, N., Marshall, T., Piscopo, K. D., Korsen, N., Lynch, S., Karnell, L. H., ... & Ghose, S. S. (2018). Screening for behavioral health conditions in primary care settings: A systematic review of the literature. Journal of general internal medicine, 33(3), 335-346. 7. King, M., Semlyen, J., Tai, S.S., Killaspy, H., Osborn, D., Popelyuk, D., & Nazareth, I. (2008). A systematic review of mental disorder, suicide, and deliberate self-harm in lesbian,

gay and bisexual people. BMC Psychiatry, 8, 70. 8. Liu, R. T., & Mustanski, B. (2012). Suicidal ideation and selfharm in lesbian, gay, bisexual, and transgender youth. American journal of preventive medicine, 42(3), 221-228. 9. Breiding, M. J., Smith, S. G., Basile, K. C., Walters, M. L., Chen, J., & Merrick, M. T. (2015). Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization—National Intimate Partner and Sexual Violence Survey, United States, 2011. American journal of public health, 105(4), E11. 10. Meckler, G. D., Elliott, M. N., Kanouse, D. E., Beals, K. P., & Schuster, M. A. (2006). Nondisclosure of sexual orientation to a physician among a sample of gay, lesbian, and bisexual youth. Archives of pediatrics & adolescent medicine, 160(12), 1248-1254. 11. Legal, L. (2010). When health care isn’t caring: Lambda Legal’s survey of discrimination against LGBT people and people with HIV. New York: Lambda Legal. 12. Fazel, S., Khosla, V., Doll, H., & Geddes, J. (2008). The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS medicine, 5(12), e225. 13. Fitzpatrick, K. M., LaGory, M. E., & Ritchey, F. J. (1999). Dangerous places: Exposure to violence and its mental health consequences for the homeless. American Journal of Orthopsychiatry, 69(4), 438-447. 14. Irestig, R., Burström, K., Wessel, M., & Lynöe, N. (2010). How

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Year 5 Research Projects are homeless people treated in the healthcare system and other societal institutions? Study of their experiences and trust. Scandinavian Journal of Public Health, 38(3), 225-231. 15. Meng, G. (2012). Cultivating fear: The vulnerability of immigrant farmworkers in the US to sexual violence and sexual harassment. 16. Pulgar, C. A., Trejo, G., Suerken, C., Ip, E. H., Arcury, T. A., & Quandt, S. A. (2016). Economic hardship and depression among women in Latino farmworker families. Journal of immigrant and minority health, 18(3), 497-504. 17. Arcury, T. A., Sandberg, J. C., Talton, J. W., Laurienti, P. J., Daniel, S. S., & Quandt, S. A. (2018). Mental health among Latina farmworkers and other employed Latinas in North Carolina. Journal of Rural Mental Health, 42(2), 89. 18. Drewniak, D., Krones, T., & Wild, V. (2017). Do attitudes and behavior of health care professionals exacerbate health care disparities among immigrant and ethnic minority groups? An integrative literature review. International journal of nursing studies, 70, 89-98. 19. Bjorkenstam E, Burstrom B, Brannstrom L, Vinnerljung B, Bjorkenstam C, Pebley AR. Cumulative exposure to childhood stressors and subsequent psychological distress. An analysis of US panel data. Soc Sci Med. 2015;142:109-17. Epub 2015/08/25. doi: 10.1016/j.socscimed.2015.08.006. PubMed PMID: 26301483.

5th Annual Communities of Practice Conference 20. Gwadz MV, Gostnell K, Smolenski C, Willis B, Nish D, Nolan TC, et al. The initiation of homeless youth into the street economy. Journal of Adolescence. 2009;32(2):357-77. doi: http://dx.doi.org/10.1016/j.adolescence.2008.01.004. 21. Paalman CH, Terwee CB, Jansma EP, Jansen LMC. Instruments Measuring Externalizing Mental Health Problems in Immigrant Ethnic Minority Youths: A Systematic Review of Measurement Properties. PLoS ONE. 2013;8(5):e63109. doi: 10.1371/journal.pone.0063109. PubMed PMID: PMC3660354.

HUMAN SUBJECTS RESEARCH One of the activities involves human subjects. Students at four HBCU medical schools will be contacted to complete a survey on how well they feel they were prepared to address mental health in vulnerable populations. A proposal will be submitted to the MMC IRB for approval prior to initiating the research.

KEY STAFF QUALIFICATIONS: Paul D. Juarez, PhD, Program Director is Vice Chair for Research in the Department of Family and Community Medicine and Director of the Health Disparities Research Center of Excellence at Meharry Medical College and serves as the Director of the Tennessee Area Health Education Center (AHEC). Dr. Juarez also is PI of a research grant to increase PrEP uptake and adherence among young black MSM in Memphis, TN and previously served as the PI of the Nashville Urban Partnership Academic Center of Excellence to Prevent Youth Violence. Mohammad Tabatabai, PhD, Director, Statistical Methods, is a Professor of Biostatistics at Meharry Medical College. Dr. Tabatabai current research is in cancer modelling, premature death, diabetes in Mid-Cumberland region of Tennessee, and HIV/HCV coinfection. He is a member of the research team preparing to analyze the combined Meharry-Vanderbilt data on HIV/HCV coinfection. He is also a member of the Biostatistics and Biomedical Informatics Core (BBIC) for the Tennessee Center for AIDS Research (TN-CFAR) assisting HIV researchers with the design and analysis of their research proposals. The BBIC provides statistical and biomedical informatics support to HIV/AIDS investigators at Meharry Medical College, Vanderbilt University, and the Tennessee Department of Health. He has recently joined the Research Design, Biostatistics and Clinical Research Ethics (DBRE) Core of the Meharry Clinical and Translational Research Center (MeTRC). He has done extensive research in breast, brain, prostate cancer as well as modeling tumor growth such as glioblastoma multiform type IV, hypertabastic survival analysis and their applications in medical genomics, robust linear and nonlinear regression models including logistic, probit and multinomial regression models and cellular growth models. Dr. Tabatabai has recently been honored with the prestigious Professor of the Year Award by the Meharry Medical College pre alumni association.

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R. Lyle Cooper, PhD (PI), has been a Licensed Clinical Social Worker since 2005. Dr. Cooper has worked with the LGBT population since 1999 when he began his work as an HIV outreach worker funded through the NIDA Indigenous Street Outreach Worker Model Study. He presently serves as PI on an NIAID sub award from the Tennessee Center for AIDS Research examining the role of stress (as measured through salivary cortisol) related to racial and sexual orientation discrimination and HIV related stigma among Black men that have sex with men (MSM), and the role of this stress in HIV disease progression. He is also the PI on a SAMHSA funded study to reduce HIV risk behaviors and substance abuse among young Black MSM. He is also an experienced educator with 14 years of teaching experience. He has served on curriculum committees, and developed two specializations, the Spalding University Alcohol and Drug Counseling Specialty Certificate, and the University of Tennessee, College of Social Work’s Doctorate in Clinical Social Work program, where he worked on the committee that developed the program.

CONTENT EXPERT CONSULTANTS: Leandro Mena, MD, Associate Professor, Internal Medicine, University of Mississippi and Jackson State University. Tom Arcury, PhD, Professor and Vice Chair for Research, Family and Community Medicine, Wake Forest University Beth Shinn, PhD, Professor, Human & Organizational Development, Vanderbilt University

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YEAR 5 POLICY BRIEF

Systematic Review of Mental Health Training for Medical Students and Residents WHO THE POLICY BRIEF IS AIMED AT? » Curriculum planners in medical schools » Education policy makers in government and advisory bodies (Health Resources Services Administration, National Institutes of Health, Association American Medical Colleges, Liaison Committee on Medical Education, Southern Association of Colleges and Schools, Council on Education for Public Health, National Medical Association and medical societies, as well as non-governmental organizations focusing on mental healthcare for vulnerable populations such as LGBTQ+, persons experiencing homelessness, and migrant farm workers)

KEY MESSAGES » This policy brief provides guidance on how to train medical students and residents in mental health in order to assess, identify and address mental health and improve care among gender and sexual minorities (GSM), people experiencing homelessness, and migrant farm workers. » Mental health education can help government, care providers, and educators as well as healthcare systems to adopt recommendations and normalize the provision of mental health care. » Mental health training can contribute to policy making in regard to providing equal access to high quality care for GSM, people experiencing homelessness, and migrant farm workers. » This policy brief also calls for ensuring that healthcare professionals’ practice cultural humility in addressing the health issues of GSM people experiencing homelessness, and migrant farm workers towards achieving health equity.

POLICY OPTIONS » Existing information on mental health care should be considered and evaluated before proposing and accepting the curricular interventions. » Multidisciplinary engagement of stakeholders (general public, patients/consumers, patient community advocacy groups and care providers) is necessary to develop the objectives for curricular changes before policy making.

POLICY RELEVANCE » Mental health care specifically for LGBTQ+, people experiencing homelessness, and migrant farm workers has been identified as an emerging area which has not received adequate attention in medical education or residency training resulting in a workforce that is illprepared to provide culturally responsive and appropriate care for these populations.

EXECUTIVE SUMMARY Medical students and residents currently lack appropriate and sufficient training on how to provide mental health treatment for LGBTQ+, people experiencing homelessness, and migrant farm workers. This policy brief advocates for equipping students and residents with knowledge and skills to provide culturally responsive and appropriate care. It is expected that the curricular interventions on mental health care will result in perceived and quantifiable improvements in patient care.

INTRODUCTION/STATEMENT OF THE PROBLEM Mental health disorders in the United States remain undertreated.1 This is further pronounced in LGBTQ+, homeless, and migrant farm working populations.2-4 Training for medical students and residents to treat health conditions specific to these vulnerable populations is sporadically taught throughout medical schools leading to a scarcity of health care providers comfortable with the diagnosis and treatment of their needs.5-6 A 2009-2010 survey administered to medical school deans about LGBTQ+ related content in medical education found that the median reported time dedicated to LGBTQ+-related topics was small (e.g., 5 hours) and that the quantity, content covered, and perceived quality of instruction varied substantially.7 Lack of experience with vulnerable populations has been shown to be correlated with negative attitudes.8 This limited clinical training specific to vulnerable populations can lead students and residents to be less effective when communicating and treating these patients. While some measures have been taken to increase the quality of care to vulnerable populations, the level of care remains lower than what is provided to other populations.9

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METHODS/APPROACHES In order to identify and assess how medical students and residents are being trained to provide mental health care for LGBTQ+, people experiencing homelessness, and migrant farm workers, we conducted a systematic review of literature from 1990 to 2020. We used PRISMA guidelines to identify original studies that focused on medical education, including medical school and residency training, to increase knowledge and comfort, as well as improve attitudes, skills, and confidence of medical students and residents providing care to for LGBTQ+, people experiencing homelessness, and migrant farm workers. Our search included 6 databases (Google Scholar, PubMed, PsychInfo, ERIC, Web Of Science, and CINAHL). The search strategy cross-referenced keywords for mental health (anxiety disorder, panic disorder, personality disorder, post-traumatic stress disorder, mood disorder, depression with keywords for medical treatment; adolescent psychiatry, child psychiatry, community psychiatry, or neuropsychiatry and keywords for medical students or residents; medical students, residents, medical education, training, curriculum). Data extraction from the articles focused on criteria such as study description, study design, educational intervention etc. Study quality was evaluated by authors using published recommendations.

RESULTS A total of 2,449 articles were identified and screened by various inclusion and exclusion criteria and full text review; after which 13 articles were included that had an educational intervention component and focused on medical students and/or residents. Study quality overall was moderate with most studies using quasi-experimental or pre-experimental design. The educational methods described included didactic sessions, face-to-face and virtual discussions, workshops, seminars, case presentations, ambulatory experiences, and student-run psychiatry clinics. Overall, training methods showed high satisfaction among students and residents, increased knowledge, and improved attitudes and confidence.

LIMITATIONS AND CHALLENGES » » » »

Studies that assess skills such as Objective Structured Clinical Examinations are lacking Lack of research on outcomes of graduate medical education (GME) training in mental health Limited generalizability of findings due to small sample sizes Very few studies focused on vulnerable populations who are at elevated risk of mental health conditions

POLICY RECOMMENDATIONS » » » » » » » »

Standardize measures to assess learning outcomes regarding mental health care. More training intervention strategies should be employed in GME training Develop curriculum modules on “Mental Health Treatment” and pilot test these modules in medical schools and in residency. Engage LGBTQ+, people experiencing homelessness, and migrant farm workers with legal, health care, finance, social work and community engagement backgrounds as part of clinical networks and working groups. Monitor mental health outcomes of LGBTQ+, people experiencing homelessness, and migrant farm workers to assess the quality of care received both in outpatient and inpatient care settings. Encourage more experienced clinicians (multiple years of experience) to mentor less experienced students and clinicians (during clerkship, residency and early years of practice) in mental health healthcare. Establish privacy, confidentiality, and cultural humility guidelines in patient care settings. Establish and normalize interprofessional team based care to address multifaceted needs of patients including mental health care.

ACKNOWLEDGMENTS This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UH1HP30348, entitled academic Units for Primary Care Training and Enhancement. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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SOURCES 1. Wang, P. S., Lane, M., Olfson, M., et al. (2005). Twelve-month use of mental health services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 629–640 2. K.J. Hodgson, K.H. Shelton, M.B.M. van den Bree Mental health problems in young people with experiences of homelessness and the relationship with health service use: A follow-up study Evidence-Based Mental Health, 17 (3) (2014), pp. 76-80 3. Cochran SD, Mays VM. Physical health complaints among lesbians, gay men, and bisexual and homosexually experienced heterosexual individuals: Results from the California Quality of Life Survey. Am J Public Health 2007;97:2048–2055. 4. Ramos AK, Su D, Lander L, Rivera R. Stress factors contributing to depression among Latino migrant farmworkers in Nebraska. Journal of Immigrant and Minority Health. 2015;17:1627–1634. doi: 10.1007/s10903-015-0201-5. 5. Fraser L, Knudson G. Education Needs of Providers of Transgender Population. Endocrinology and Metabolism Clinics of North America. 2019;48(2):465-477.

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6. Vance SR, Deutsch MB, Rosenthal SM, Buckelew SM. Enhancing Pediatric Trainees’ and Students’ Knowledge in Providing Care to Transgender Youth. Journal Of Adolescent Health. 2017;60(4):425430 7. Dubin SN, Nolan IT, Streed CG, Jr., Greene RE, Radix AE, Morrison SD. Transgender health care: improving medical students' and residents' training and awareness. Adv Med Educ Pract. 2018;9: 377-391. 8. Shidlo A. Assessing heterosexuals’ attitudes toward lesbian and gay men. In: Greene B, Here GM, editors. Psychological perspectives on lesbian and gay issues, vol. 1. Lesbian and gay psychology: theory, research, and clinical applications. Thousand Oaks: Sage; 1994. p. 176–205. 9. Fadus M. Mental Health Disparities and Medical Student Education: Teaching in Psychiatry for LGBTQ Care, Communication, and Advocacy.

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YEAR 5 RESEARCH TOPIC

Preparing Medical Students to Use Telehealth to Address Disparities among Vulnerable Populations PI: Patricia Matthews-Juarez, PhD, pmatthews-juarez@mmc.edu (615) 327-6526 Contact person: Paul D. Juarez, PhD, pjuarez@mmc.edu (615) 327-6992 Date funded: UH1HP30348/ 07/01/2016 – 06/30/2021

PROJECT SUMMARY Project Description: This research project will assess how and why telehealth has been widely adapted in response to the COVID 19 pandemic, its use and effectiveness in providing primary care, and its potential for enhancing the provision of primary care services to vulnerable populations. It will use mixed, quantitative and qualitative methods and analytics to assess what and how medical students are being taught to use telehealth effectively to promote health and manage chronic conditions and ideas of how telehealth can be used to better address the needs of vulnerable populations. Statement of the problem, gaps in current research: Healthcare systems have had to modify the way they triage, evaluate, and care for patients during the current COVID 19 pandemic by using methods that do not rely on in-person services. Changes in the way that health care is delivered have been adapted to increase social distancing, reduce staff exposure to ill persons, preserve personal protective equipment (PPE), and minimize the impact of patient surges on facilities. Greater reliance on the use of telehealth services has enabled continued provision of necessary care to patients while minimizing the transmission risk of COVID-19 between healthcare personnel (HCP) and patients. Use of telehealth to deliver health care must be quickly integrated into medical education curriculum to prepare students to adapt to the rapidly changing dynamics brought about by COVID 19. Teleheath poses exciting opportunities for new and innovative uses to address the unique needs of vulnerable populations.

RESEARCH QUESTIONS OR HYPOTHESIS: » What is the current level of knowledge, awareness, and skills of medical students in using telehealth to provide clinical and preventive care? » What experience do medical students have in using telehealth to provide patient care? » What advantages and barriers do medical students foresee in using telehealth to provide primary care services to vulnerable populations?

PROJECT GOALS: » To conduct a scoping review of the social, political, and technological environment for continued and/or expanded use of telehealth services. » Conduct a survey of medical students of their knowledge, awareness, and skills in using telehealth to provide primary care services. » Evaluate the effectiveness of a curriculum module for teaching medical students how to use telehealth to provide effective primary care services. » Conduct four focus groups of medical students to explore how telehealth services might be used to improve the provision of primary care services to vulnerable populations.

RESEARCH DESCRIPTION STATEMENT OF THE PROBLEM Telehealth and other forms of health information technology can provide a new avenue of access to healthcare for vulnerable populations, especially those with chronic diseases, who otherwise might not seek or receive it. Telehealth technology, including use of mobile devices provides new opportunities for reducing barriers to health care, coordinating care, managing chronic conditions, enhancing medication adherence, and receiving quicker medication changes from their doctor, and self-efficiency. Telehealth technology provides a safe option for both health care providers (HCP) and patients, minimizes barriers such as transportation and perceived discrimination, and creates opportunities for social engagement and a reduction of social isolation. Recent emergency policy changes by federal and state government to reimburse providers for telehealth services in response the COVID-19 pandemic have reduced barriers for the delivery of acute, chronic, primary and specialty care. Sustained support for telehealth services provides a long term strategy for reducing real and perceived barriers to accessing primary care by vulnerable populations.

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TARGET POPULATIONS/CHARACTERISTICS: LGBTQ. New data from a nationally representative CAP survey conducted in 2017 show that LGBTQ people experience discrimination in health care settings; that discrimination discourages them from seeking care; and that LGBTQ people may have trouble finding alternative services if they are turned away. Seventeen percent of LGBTQ respondents and 19 percent of transgender people reporting avoidance seeking medical care in the previous year due to fear of discrimination. In a recent survey, 29% of transgender patients said that a doctor or other health care provider refused to see them because of their actual or perceived gender identity. Discrimination deters many LGBTQ people from seeking health care. Discrimination in health care settings endangers LGBTQ people’s lives through delays or denials of medically necessary care. While there have been major advances in protecting the rights of LGBTQ persons in recent years, there are current efforts to make it easier for health care providers to discriminate against LGBTQ men and women. Denial of health care services are particularly acute for transgender patients. On August 23, 2016, eight states and a group of conservative religious organizations filed a lawsuit against the U.S. Department of Health and Human Services (HHS), challenging rule 1557, the nondiscrimination provision of the Affordable Care Act (ACA). (Rule 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in federally funded health programs). The plaintiffs claimed that the nondiscrimination protections would require doctors to provide treatment in violation of their religious beliefs, such as transition-related surgeries for transgender patients. Even though a number of courts have ruled that laws such as 1557 protect LGBTQ people, in December 2016, a judge in federal district court in the northern district of Texas issued a nationwide injunction prohibiting HHS from enforcing the 1557 rule’s prohibition on discrimination on the basis of gender identity. On May 2, 2017, the Trump administration filed a motion indicating that the 1557 rule was under review, and in August, it announced that HHS had already written a draft proposal to roll back the rule. Persons Experiencing Homelessness (PEH). PEH often have multiple complex health conditions yet typically are disengaged from the primary health care system. They frequently experience multiple barriers to accessing services including lack of knowledge and awareness of the healthcare system and perceived stigma and discrimination.1 Other barriers which prevent PHE from accessing primary care include illness and poor health, physical access to health services, difficulty in contacting services, medication security, and the affordability of health care. Differences in social status and perceptions of being judged are additional barriers for homeless persons in accessing primary care services. The Veterans Administration has piloted the use of telehealth and nurse care management to promote chronic illness self-management among PEH, using personal messaging devices to provide disease-specific health education and generate daily questions about relevant clinical indicators from chronic illness care guidelines. These messaging devices have been linked to peripheral equipment, e.g., sphygmomanometers, which transmit information to VA nurses who monitor symptoms and adherence to recommendations. Telehealth and related health information technologies offer exciting new opportunities for providing increased access to care by PEH. Migrant Farm Workers Migrant farm workers (MFW) bear a disproportionate burden of poverty, health disparities, occupational hazards, and barriers to accessing healthcare. 2 Many MFW are foreign born seasonal workers, are not protected by sick leave, and risk losing their jobs if they miss a day of work. Cultural and language differences, lack of transportation, and deficient health insurance often discourage them from seeking care. Telehealth and related health information technologies offer exciting new opportunities for providing increased access to care by PEH.

HYPOTHESES, DESIGN, AND ANALYSIS HYPOTHESES: » What is the current level of knowledge, comfort, and skills of medical students IN using telehealth technology to deliver care to vulnerable populations? » How are medical students being prepared to use telehealth to provide primary care? » How do medical students perceive the use of telehealth services in providing primary care services to vulnerable populations?

DESIGN. This research will employ mixed methods to assess how telehealth currently is being used, strengths and weaknesses of the use of telehealth, and its potential for increasing access to care and quality of patient outcomes of vulnerable populations. It will assess knowledge, awareness, and skills of medical students in using telehealth, their experience in using it for patient care, and their attitudes about its use to provide care in the future with pre/post surveys

ANALYSIS Data will be analyzed using traditional statistical methods, including descriptive, univariate, correlational and regression analytics.

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LITERATURE CITED 1. Gunner E, Chandan SK, Marwick S, et al. Provision and accessibility of primary healthcare services for people who are homeless: a qualitative study of patient perspectives in the UK. Br J Gen Pract. 2019;69(685):e526-e536. 2. Frank A. Liebman AK RB, Weir, M, Arcury TA. AMERICAN JOURNAL OF INDUSTRIAL MEDICINE. 2013:1-15.

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YEAR 5 POLICY BRIEF

Transforming Medical Education to Address the Health Issues of Vulnerable Populations Through Telehealth Training

WHO THE POLICY BRIEF IS AIMED AT? » Curriculum planners in medical schools (undergraduate and graduate medical education programs), medical school faculty and academicians » Education policy makers in government and advisory bodies (Health Resources Services Administration-HRSA; National Institutes of Health-NIH; American Association of Medical Colleges-AAMC; Liaison Committee on Medical Education- LCME; Southern Association of Colleges and Schools-SACS; Council on Education for Public Health- CEPH; National Medical Association- NMA; American Medical Association-AMA and medical societies)

KEY MESSAGES » Telehealth policy brief could provide information for trainees, educators and patients on best practices in telemedicine. » Telehealth policy brief can provide government and health care providers with guidelines on how to use telehealth to address the needs of vulnerable populations. » Telehealth policy brief can provide policy makers with information on how telehealth can be used to provide equal access to high quality care by vulnerable populations (Lesbian, Gay, Bisexual, Transgender, Queer and/or Questioning-LGBTQ individuals, people experiencing homelessness and migrant farmworkers). » This policy brief recommends that health professions training programs teach students how to practice cultural humility in addressing the health issues of gender and sexual minorities and other socially vulnerable populations via telehealth.

POLICY OPTIONS » Evaluation of existing information on telehealth training should be considered prior to proposing and accepting the existing curricular interventions. » Input from stakeholders about the use of telehealth to address the health issues of gender and sexual minorities and other socially vulnerable populations via telehealth (public, patients, community advocacy groups and care providers) should be obtained before policy making.

POLICY RELEVANCE Health care delivery through telehealth has been identified as an emerging strategy for providing healthcare for vulnerable populations yet it has not received adequate attention in medical education or residency training resulting in an ill-prepared workforce. Cultural humility, mobility, language, literacy levels, health literacy levels and internet access to healthcare present challenges for how telehealth can be used to achieve health equity in socially vulnerable patients.

EXECUTIVE SUMMARY Differences in social status and perceptions of being judged are barriers for socially vulnerable populations in accessing and receiving primary care services. Medical students and residents currently are hindered by a lack of training on how to use telemedicine to provide socially and culturally appropriate care to LGBTQ patients and other vulnerable groups. The proposed policy brief promotes strategies to use telehealth to equip medical students and residents with knowledge and skills to provide culturally competent care. It is expected that the telehealth curricular interventions will result in improvements in qualitative and quantifiable care of patients from vulnerable populations.

INTRODUCTION/STATEMENT OF THE PROBLEM Telehealth and other forms of health information technology including but not limited to the use of mobile devices can provide a new avenue of access to healthcare for vulnerable populations, especially those with chronic diseases, who otherwise might not seek or receive it. Telemedicine provides new opportunities for reducing barriers to health care, coordinating care, managing chronic conditions, enhancing medication adherence, and receiving quicker medication changes from their doctor, self-efficiency and decreasing costs.1 Telehealth technology provides a safe option for both health care providers (HCP) and patients. It minimizes care barriers such as clinic hours,

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transportation and perceived discrimination, and creates opportunities for social engagement and a reduction of social isolation.2 In recent times many providers are using interdisciplinary telemedicine to provide individualized patient-centered care. The COVID-19 pandemic has highlighted the value of telehealth in providing primary care to patients. Difficulties in maintaining social distance and the concerns associated with spread of disease prevented many patients from seeking care. At the onset of the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. These policy changes build on the regulatory flexibilities granted under the President’s emergency declaration. CMS expanded this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans – particularly those at high-risk of complications from the virus that causes the disease COVID-19 – are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of this virus. Without further legislative action, however, these policy changes will expire when the pandemic is declared to be over. Healthcare systems have had to modify the way they triage, evaluate, and care for patients during the current COVID 19 pandemic by using methods that do not rely on in-person services. Changes in the way that health care is delivered have been adapted to increase social distancing, reduce staff exposure to ill persons, preserve personal protective equipment (PPE), and minimize the impact of patient surges on facilities. Greater reliance on the use of telehealth services has enabled continued provision of necessary care to primary care patients while minimizing the transmission risk of COVID-19 between HCP and patients.3 In addition to the general public benefitting from telemedicine, telehealth care has been found to be very useful in supporting access to treatment for hundreds of people who were released from incarceration early due to the pandemic.4 Telehealth presents exciting opportunities for new and innovative uses to address the unique needs of vulnerable populations, which are the target of this policy brief. Support for sustained telehealth services provides a long-term strategy for reducing real and perceived barriers to accessing primary care by vulnerable populations. However, it does not mask systemic problems of in-person care, such as discrimination in health care settings that discourages them from seeking or obtaining care. Discrimination in health care settings endangers LGBTQ people’s lives through discouraging, delaying, or denying access to medically necessary care.5 While there have been major advances in protecting the rights of LGBTQ persons in recent years, there are current efforts to make it easier for health care providers to discriminate against LGBTQ men and women. Telehealth may alleviate health challenges for gender and sexual minorities in the COVID-19 era.6 Another vulnerable populations that could benefit from telehealth use are persons experiencing homelessness (PEH). PEH often have multiple complex health conditions, yet typically are disengaged from the primary health care system. They frequently experience multiple barriers to accessing services including lack of knowledge and awareness of the healthcare system, stigma and discrimination.7 Barriers which prevent PHE from accessing primary care include but not limited to chronic illnesses and poor health, physical access to health services, difficulty in contacting services, and costs of care and prescription drugs. Telehealth case management intervention for homeless-experienced people living with HIV was found to be beneficial in the first wave of COVID pandemic.8 Recently, students in the Dartmouth’s Geisel School of Medicine used telehealth to treat people experiencing homelessness.9 Migrant Farm Workers (MFW) represent another vulnerable population group. MFW bear a disproportionate burden of poverty, health disparities, occupational hazards, and barriers to accessing healthcare.10 Many MFW are foreign born seasonal workers, are not protected by sick leave, and risk losing their jobs if they miss a day of work. Cultural and language differences, lack of transportation, and deficient health insurance often discourage them from seeking care. Telehealth and related health information technologies offer exciting new opportunities for providing increased access to care by MFW. While some migrant farm workers have access to mobile phones and are willing to use mHealth devices11, others who are seasonal workers in rural settings do not have access to mobile phones or internet.12 Use of telehealth to deliver quality health care must be integrated into medical education curriculum to prepare students to adapt to this new health care delivery model brought about by COVID 19.13 There are an increasing number of medical residency specialty and sub¬specialty programs, including OB/GYN, Endocrinology, Urology, Surgery, Psychiatry, Otolaryngology etc., that have identified the need for residents to receive training in telehealth for vulnerable populations. Little curriculum time of medical schools currently is allotted to addressing the unique, needs of socially vulnerable populations. In such situations, telemedicine platforms are ideal as these allow interactive evaluation and treatment of patients in few interdisciplinary settings.14 For e.g., transgender patients require specialists from reproductive medicine, endocrinology, surgery, mental health, internal medicine etc. Telehealth portals can facilitate consultation with all the specialists in one visit. This type of interaction works well both for patient, health care providers in addition to saving time and costs. Situations imposed by the pandemic have challenged medical educators with finding ways to integrate trainees into virtual workflows and at the same time be able to provide patient-centered virtual care.15 Towards this end, there is a greater need to assess how medical students and residents are being taught to use telehealth to manage acute and chronic health conditions.

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METHODS/APPROACHES In order to identify and assess how medical students and residents are being trained to provide socially and culturally health care to generaland socially vulnerable patients through telehealth, we have conducted a systematic review of literature from 2000 until 2020. We used PRISMA guidelines16 to identify original studies that focused on medical school training to increase knowledge and comfort, as well as improve the attitudes and skills of medical students and residents working with GSM patients. Our search included the databases such as Google Scholar, PubMed, ERIC, Web of Science, CINAHL, PsychInfo, and MedED Portal. The search strategy cross-referenced keywords for Telehealth OR telemedicine OR mobile health OR e-Health OR remote consultation OR telepathology OR telerehabilitation separated by OR/AND with keywords for medical students and residents (medical student, medical resident), and medical education (medical school curriculum, basic science, clinical, rotations, objective structured clinical examination [OSCE], standardized patient). Data extraction from the articles focused on criteria such as study description, study design, educational intervention etc. Study quality was evaluated by a triad of authors using published recommendations.17

RESULTS Out of a total of 96 articles screened and subjected to various inclusion and exclusion criteria, and full text review, only 6 articles were identified that has a telehealth educational intervention that focused on medical students and/or residents. Study quality overall was low to moderate and limited to quasi and non-experimental designs. The majority of the studies focused on medical student training, and few included residents. The educational/training methods described included didactic sessions, small group discussions, and interactive livestreamed virtual videos. Overall, employing telehealth training methods are promising at the undergraduate medical education (UME) level.

LIMITATIONS/CHALLENGES » Medical schools and residency programs may be resistant to additional curriculum demands. » There is a dearth of evaluation of training approaches that use longer term assessments of attitude, comfort, and belief changes in students and residents. » Measures to assess objective skill (e.g., OSCE’s; practice observation) are lacking in the studies that were reviewed. » There is a greater need for graduate medical education (GME) training in telehealth. » There were no articles addressing telehealth training aimed at other vulnerable populations, which include migrant farm workers or individuals experiencing homelessness.

POLICY RECOMMENDATIONS » Standardize measures to assess learning outcomes regarding telehealth. » Develop curriculum modules on telehealth with emphasis on patient-centered telemedicine competencies and pilot test these modules in medical schools. » Engage LGBTQ individuals, people experiencing homelessness and migrant farm workers and their advocacy groups with legal, health care, finance, social work and community engagement backgrounds as part of clinical network & working groups. » Monitor health outcomes of patients to assess the quality of care received through telehealth. » Emphasize privacy, confidentiality during patient consultations using telehealth and cultural humility especially in dealing with transgender patients. » Embolden insurance companies, hospital administration, and government agencies to work together to reduce/eliminate barriers in reimbursement policies, state and federal regulations, cyber and Health Insurance Portability and Accountability (HIPAA) security acts, and train in technology education and utilization. » Encourage academic medical centers and hospitals to partner with non-profit foundations to establish telehealth kiosks so that people experiencing homelessness and those in transitional housing could seek much needed care. » Familiarize patients and support staff in care provider’s organization regarding robotic system applications and remote monitoring technologies associated with telehealth. » Seek regulatory guidance to develop safe, secure, provider and patient-friendly telehealth applications.

ACKNOWLEDGMENTS This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UH1HP30348, entitled academic Units for Primary Care Training and Enhancement. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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SOURCES 1. Wang E, Real I, David-Wang A, Rubio DA, Gaston CL, Quintos AJ, Dimayuga C, Dacanay E. Lessons learned: Patient communication during the pandemic. Malays Orthop J. 2021; 15 (1):12-15. 2. Ramos G and Chavira DA. Use of technology to provide mental health care for racial and ethnic minorities: evidence, promise, and challenges. Cognitive and Behavioral Practice. 2019 3. Weber AM, Dua A, Chang K, Jupalli H, Rizwan F, Chouthai A, Chen C. An outpatient telehealth elective for displaced clinical learners during the COVID-19 pandemic. BMC Med Educ. 2021 Mar 20;21(1):174. 4. Komaromy M, Tomanovich M, Taylor JL, Ruiz-Mercado G, Kimmel SD, Bagley SM, Saia KM, Costello E, Park TW, LaBelle C, Weinstein Z, Walley AY. Adaptation of a system of treatment for substance use disorders during the COVID-19 Pandemic. J Addict Med. 2020 Dec 8. doi: 10.1097/ADM.0000000000000791. 5. Morris M, Cooper RL, Ramesh A, Tabatabai M, Arcury TA, Shinn M, Im W, Juarez P, Matthews-Juarez P. Training to reduce LGBTQrelated bias among medical, nursing, and dental students and providers: a systematic review. BMC Med Educ. 2019 Aug 30;19(1):325. 6. Holloway IW, Garner A, Tan D, Ochoa AM, Santos GM, Howell S. Associations between physical distancing and mental health, sexual health and technology Use among gay, bisexual and other men who have sex with men during the COVID-19 Pandemic. J Homosex. 2021; 68(4):692-708. 7. Gunner E, Chandan SK, Marwick S, et al. Provision and accessibility of primary healthcare services for people who are homeless: a qualitative study of patient perspectives in the UK. Br J Gen Pract. 2019; 69(685): e526-e536. 8. Brody JK, Rajabiun S, Strupp Allen HJ, Baggett T. Enhanced telehealth case management plus emergency financial assistance for homeless-experienced people living with HIV during the COVID-19 Pandemic. Am J Public Health. 2021;111(5):835-838. 9. Heflin KJ, Gillett L, Alexander A. Lessons from a Free Clinic During Covid-19: Medical students serving individuals experiencing homelessness using Tele-Health. J Ambul Care Manage. 2020;43(4):308-311.

10. Frank AL, Liebman AK, Ryder B, Weir M, Arcury TA. Health care access and health care workforce for immigrant workers in the agriculture, forestry, and fisheries sector in the southeastern US. Am J Ind Med. 2013;56(8):960-74. 11. Price M, Williamson D, McCandless R, Mueller M, Gregoski M, Brunner-Jackson B, Treiber E, Davidson L, Treiber F. Hispanic migrant farm workers' attitudes toward mobile phone-based telehealth for management of chronic health conditions. J Med Internet Res. 2013;15(4):e76. 12. Lee JGL, LePrevost CE, Harwell EL, Bloss JE, Cofie LE, Wiggins MF, Firnhaber GC. Coronavirus pandemic highlights critical gaps in rural Internet access for migrant and seasonal farmworkers: a call for partnership with medical libraries. J Med Libr Assoc. 2020;108(4):651-655. 13. Wamsley M, Cornejo L, Kryzhanovskaya I, Lin BW, Sullivan J, Yoder J, Ziv T. Best practices for integrating medical students into telehealth visits. JMIR Med Educ. 2021;7(2): e27877. 14. Zughni LA, Gillespie AI, Hatcher JL, Rubin AD, Giliberto JP. Telemedicine and the interdisciplinary clinic model: During the COVID-19 Pandemic and beyond. Otolaryngol Head Neck Surg. 2020;163(4):673-675. 15. Alcocer M, Lenti G, Choo ZY, Castaneda J, Lee WW. Teaching telemedicine: The next frontier for medical educators. JMIR Med Educ. 2021 Apr 15. doi: 10.2196/29099. 16. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta- analyses: the PRISMA statement. J Clin Epidemiol. 2009 Oct;62(10):1006– 12. 17. Hammick M, Dornan T, Steinert Y. Conducting a best evidence systematic review. Part1: from idea to data coding. BEME Guide No. 13. Med Teach. 2010 Jan;32(1):3– 15.

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Methods

OVID N = 161 SCOPUS N = 334

Records after full-text articles reviewed N = 15

Records filtered after inclusion criteria N = 29

Records after filtering N = 564

Records after duplicates removed N = 626

Records identified through databases searching N = 715

ERIC N=0 PsychInfo N=3

English language Publication year 1998 to 2018 Journal articles Pharmacy Nursing Medical schools Osteopathic schools Resident physicians Undergraduate programs Addressed research question

Books (N = 56) Conference proceedings (N = 3) Dissertation/Thesis (N = 3)

Web of Science N = 63

• What is missing in ACEs education? Screening for ACEs and provision of trauma-informed care (TIC).

• Six studies focused primary care providers (Bassuk, 1999; Tavakkoli et al., 2014; Green et al., 2015; van den Heuvel et al., 2017; Bethell et al., 2017; Pardee et al., 2017).

• One study focused residency training programs (Tink et al., 2017).

• Two studies addressed the needs of medical students (Magen & DeLisser, 2017).

• Few articles reviewed efforts to train primary care providers (Tavakkoli et al., 2014; Green et al., 2015; Bethell et al., 2017; Magen & DeLisser, 2017; Pardee et al., 2017; Tink et al., 2017; van den Heuvel et al., 2017; Goldstein et al., 2018).

• ACE-vulnerable populations: migrant farmworkers, persons experiencing homelessness, and LGBTQ persons.

• Lack of attention to ACEs by physicians: lack of familiarity with ACEs screening, and lack of training

• Little evidence to show that ACEs screening and TIC are incorporated into . the undergraduate medical education curriculum.

Results

The search process initially identified 715 abstracts. After duplicates, reviews, and editorials were removed, 29 articles were assessed for eligibility . Further scrutiny resulted in 15 articles included in qualitative synthesis.

Figure 1. Flowchart of Study Selection.

PubMed N = 152

Search results

PRISMA Flowchart

• Review protocol: PRISMA guidelines and RefWorks citation manager.

• MeSH terms used: Adverse Childhood Exposures/Experiences, Problem Based Learning, Didactic, Curriculum, Simulation, Continuing Medical Education, Medical-, Osteopathic Schools, and Undergraduate Programs.

• Databases searched: PubMed, ERIC, SCOPUS, Web of Science, OVID, CINAHL, and Psych INFO.

• Systematic review of databases: to assess the evidence of training medical students to conduct screening and treating the effects of ACEs in general- and vulnerable populations.

• Consequences of ACEs: increased risk for multiple adverse health and mental health outcomes and poorer quality of life.

• Impact of ACEs: lasting alterations to the endocrine, autonomic, and central nervous system.

• ACE categories: psychological abuse, physical abuse, sexual abuse; substance abuse, mental illness, violent treatment of mothers, and criminal behavior in the household.

• ACEs occurrence: early in life but have effects that, without intervention, can last a lifetime.

Background

DISCUSSION/CONCLUSION: While research documents a strong correlation between the number of ACE encounters experienced during childhood and adverse health outcomes of adulthood, our systematic review found little evidence to suggest medical schools are addressing ACEs in their curricula. One of the key strategies for reducing bias is development of a curriculum that focuses not only on increasing awareness of ACEs but also allows students to practice bias reduction skills before treating patients in clinics.

RESULTS: Out of a total of 715 publications screened, 16 studies were identified that focused on medical education with respect to ACEs. These interventions targeted knowledge, skills, and comfort level using a variety of formats, including lectures, perspective-taking exercises, and small group discussions. Only a few articles were identified that reviewed efforts to train medical students. However, none of the interventions focused on vulnerable populations, such as migrant farm workers, persons experiencing homelessness and LGBTQ persons, who are more likely to have been exposed to ACEs.

DESIGN METHODS: To evaluate intervention studies focused on increasing awareness and enhancing ACE assessment in healthcare institutions, published articles were identified through searches of PubMed, Scopus, OVID, ERIC, PsycINFO, CINAHL and Web of Science databases using a combination of major and minor MeSH terms, which included: Adverse Childhood Exposures/Experiences, Problem Based Learning, Didactic, Curriculum, Simulation, Continuing Medical Education, Medical-, Osteopathic Schools, and Undergraduate Programs.

PURPOSE: Scientific evidence is accumulating on the contribution of Adverse Childhood Experiences (ACEs) to health issues across the life continuum. In the educational programs offered by medical schools, little time is spent on training students, who are future health care providers to offer competent care to patients with ACEs. The purpose of this systematic review was to increase awareness of ACEs among medical students and enhance quality and frequency of ACEs assessment in medical settings.

Abstract Discussion

Acknowledgements

Bassuk E. Guidance for Primary Care Clinicians. In: Health Care for the Homeless Council, ed. Trauma and Homelessness. Nashville, TN: Health Care for the Homeless Council; 1999. Bethell CD, Carle A, Hudziak J, et al. Acad Pediatr. 2017;17(7s):S51-s69. Goldstein E, Murray-García J, Sciolla AF, Topitzes J. The Permanente Journal. 2018;22:17-126. Green BL, Saunders PA, Power E, et al. Family Medicine. 2015;47(1):7-14. Magen E, DeLisser HM. Acad Pediatr. 2017;17(7s):S102-s107. Pardee M, Kuzma E, Dahlem Chin Hwa Y, Boucher N, Darling Fisher Cynthia S. Journal of the American Association of Nurse Practitioners. 2017;29(12):716-724. Tavakkoli M, Ann Cohen M, Alfonso C, M Batista S, Tiamson-Kassab M, Meyer P. Caring for Persons with Early Childhood Trauma, PTSD, and HIV: a Curriculum for Clinicians. Vol 38, 2014. Tink W, Tink JC, Turin TC, Kelly M. Fam Med. 2017;49(1):7-13. van den Heuvel M, Martimianakis MAT, Levy R, Atkinson A, Ford-Jones E, Shouldice M. BMC Medical Education. 2017;17(1):12.

References

Disseminating information via Communities of Practice annual meetings, webinars, websites and social media platforms.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UH1HP30348, entitled academic Units for Primary Care Training and Enhancement. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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Conducting a survey of medical students to assess their ACEs-related knowledge, skills and attitudes.

Developing a policy brief to be distributed to stake holders (funding agencies, policy makers, medical institutions, and accreditation bodies).

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Preparing a manuscript to communicate our findings to a peer-reviewed journal in medical education.

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Studies in Progress at NCMEDR

• Failure to consider these factors can lead to…..  misdiagnosis  poor treatment outcomes  ineffective therapeutic relationships.

• Above-mentioned factors shape the way people……  think  feel  relate to others  manage stress

• Elements of history and identity needs to include…….  risk for exposure to traumatic incidents as well as mediating factors, such as  sexual orientation and gender identity  experiences with homelessness  addiction

• Holistic treatment (individual’s history and identity) strategy in treatment planning and service provision.

• Creating TIC requires ……….  leadership  cross-system collaboration on information collection, sharing and training  common vision across public and private systems

Recommendations

• Inadequate coordination between services, and referral pathways results in unintegrated care for trauma patients.

• Unrecognized or misdiagnosed trauma leads to health care system failures.

• Findings on ACEs have not yet been translated into medical education/clinical practice.

• No studies have been conducted to assess using a TIC to address ACEs in vulnerable populations (homeless-, LGBTQ persons, and migrant farmworkers).

• There is little evidence that medical schools are addressing ACEs in their curriculum.

National Center for Medical Education Development and Research (NCMEDR) Meharry Medical College, Nashville, TN 37208

A Ramesh; M Paul; T Dixon; M Morris; RL Cooper; M Tabatabai; W Im; K Brown; P Juarez; P Matthews-Juarez

EDUCATIONAL INTERVENTIONS FOR ASSESSING ADVERSE CHILDHOOD EXPERIENCE

• Exposure to IV during childhood, adolescence, and adulthood has been found to be associated with mental health illness, addiction, obesity, cardiovascular conditions, chronic diseases, allergies, sleeping problems and suicidal ideations.

• Vulnerable populations such as LGBTQ persons, migrant farm workers, and persons experiencing homelessness are at increased risk for IV. • Approximately 63% of homeless women have experienced domestic violence in their adult lives • Migrant and seasonal farm working women report higher rates of intimate partner violence (IPV) than the national average.

• Interpersonal Violence (IV) encompasses a wide range of incidents from child abuse, youth violence, intimate partner violence, sexual violence, elder abuse, and gun violence, all of which are encountered commonly within the health care system.

Background

DISCUSSION/CONCLUSION: Despite recommendations from the AAMC, the CDC, and the WHO, our systematic review found that there is no consistency in how students are taught about IV. These limitations are a call for the need to incorporate IV education throughout medical school curriculum and clinical rotations. Additionally, students’ preexisting knowledge, attitudes and personal experiences to IV should be considered.

RESULTS: Thirteen studies were found to focus on IV medical education and training. These training components targeted knowledge and skills using a variety of formats including: lectures, perspective-taking exercises, and small-group discussions. A few articles were identified that reviewed efforts to increase awareness among medical students. However, none of the studies targeted vulnerable populations (migrant farm workers, homeless people and LGBTQ persons), who are at a greater risk of IV.

Methods

• To increase awareness and highlight the importance of integrating IV into medical school curricula.

• Introducing IV throughout the medical school curriculum will be beneficial in regards to treatment of patients with a history of IV.

• IV education needs to be delivered early to attune the trainees’ minds and influence their thinking towards achieving better patient outcomes

• Students’ preexisting attitudes and personal exposure to IV needs to be taken into account while designing curriculum.

• IV training should be tailored to address IV in vulnerable populations.

• Develop and incorporate IV training early into all medical school curricula so healthcare providers will have the skills, knowledge and confidence to properly assess and manage patients that are exposed to IV.

Summary

• Participation in intensive domestic violence clerkship was found to result in improvements in knowledge, attitudes and skills of medical students.

• A survey of 200 medical students and residents showed that their level of training on IV was inadequate and both these groups expressed desire to receive additional training.

• None of the studies that had IV training had targeted IV training for vulnerable populations (migrant farm workers, homeless people, and LGBTQ persons), who are at a greater risk of IV.

• Findings of the systematic review revealed that lack of knowledge about IV among medical students is a significant issue.

• Conduct a systematic review to analyze the literature concerning teaching interpersonal violence to medical school students. • Assess the literature to see if past and/or current IV training incorporates specific vulnerable populations such as LGBTQ, migrant farmworkers and homeless persons.

Results & Discussion

Goals & Objectives

NCMEDR 2nd Annual Communities of Practice Conference attendees and roundtable discussion about interpersonal violence.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UH1HP30348, entitled “Academic Units for Primary Care Training and Enhancement.” This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

Acknowledgements

Buranosky R, Hess R, McNeil MA, Aiken AM, Chang JC. Once Is Not Enough: Effective Strategies for Medical Student Education on Intimate Partner Violence. Violence Against Women. 2012;18(10):1192-212. doi: 10.1177/1077801212465154.

Frank E EL, Saltzman LE, Houry D, McMahon P, Doyle J. Clinical and personal intimate partner violence training experiences of U.S. medical students. J Womens Health. 2006;15(9):1071-79.

Connor PD NS, Mackey SN, Banet, MS, Tipton, NG. Intimate Partner Violence Education for Medical Students: Toward a Comprehensive Curriculum Revision. SMJ. 2012;105(4):211-15.

Sprague S, Kaloty R, Madden K, Dosanjh S, Mathews DJ, Bhandari M. Perceptions of intimate partner violence: a cross sectional survey of surgical residents and medical students. Journal of injury & violence research. 2013;5(1):1-10. doi: 10.5249/jivr.v5i1.147. PubMed PMID: 21926470.

Ernst AA, Houry D, Nick TG, Weiss SJ. Domestic Violence Awareness and Prevalence in a First-year Medical School Class*. Academic Emergency Medicine. 1998;5(1):64-8. doi: 10.1111/j.1553-2712.1998.tb02577.x.

Jonassen JA, Pugnaire MP, Mazor K, Regan MB, Jacobson EW, Gammon W, et al. The effect of a domestic violence interclerkship on the knowledge, attitudes, and skills of third-year medical students. Academic medicine: journal of the Association of American Medical Colleges. 1999;74(7):821-8. doi: 10.1097/00001888-199907000-00017. PubMed PMID: 10429592.

Heron SL, Hassani DM, Houry D, Quest T, Ander DS. Standardized Patients to Teach Medical Students about Intimate Partner Violence. The western journal of emergency medicine. 2010;11(5):500-5. PubMed PMID: 21293773.

Alpert EJ, Tonkin AE, Seeherman AM, Holtz HA. Family Violence Curricula in U.S. Medical Schools. American Journal of Preventive Medicine. 1998;14(4):27382. doi: https://doi.org/10.1016/S0749-3797(98)00008-7.

References

• Disseminating information about IV among vulnerable populations via webinars, websites, and multiple social media platforms.

• Creating a survey of medical students to assess their knowledge, skills and attitudes in relation to addressing IV.

• Preparing a manuscript to disseminate our research findings with other researchers and persons interested in IV in medical education.

• Developing a policy brief on IV to be distributed to key stakeholders (i.e., academic medical institutions, medical education accreditation bodies, policymakers, etc).

PURPOSE: Despite advances in new discoveries that transform health care, the medical education system has failed to address social determinants of health, which include disparities among vulnerable populations. One of these issues is Interpersonal Violence (IV), which impacts health across the lifespan.

DESIGN: A systematic review of literature identified strategies that will lead to an assessment of IV medical education and recommend interventions for incorporation into medical school curricula was conducted. These were identified through searches of databases employing a combination of major and minor MeSH terms.

Work-in-Progress at NCMEDR

Abstract

M Paul; T Dixon; A Ramesh; M Morris; RL Cooper; M Tabatabai; W Im; K Brown; P Juarez; P Matthews-Juarez

MEASURES FOR ENHANCING INTERPERSONAL VIOLENCE EDUCATION IN MEDICAL SCHOOLS

 In summary, the three courses address general needs of healthcare providers regarding of the profession.  Because this is a hybrid certificate program, healthcare providers can learn key concepts in their own time, and complement their training through this virtual interdisciplinary training and certification platform.  Utilizing this resource in conjunction with the on-site, face-to-face curriculum will allow health care providers and educators to focus on developing inter-professional clinical skills and practice experiences that can be offered by each institution, according to their specific needs.

IMPLICATIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

Xavier University of Louisiana grant # D34HP00006, Tuskegee University grant # D34HP00001, and Meharry Medical College grants # D34HP16299 and # UH1HP30348.

GRANT SUPPORT: This project is supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under different grant awards to each participating institution:

 Course 3 builds on the knowledge and skills acquired in the two previous courses to focus on specific chronic conditions where self-care and patient-clinician trust and relationships play crucial roles in the effective management of the conditions and better health outcomes.

 Course 2 focuses on the knowledge and skills that help healthcare providers to better understand and serve patients from diverse background.

 Course 1 emphasizes basic awareness and knowledge that all healthcare providers should have when working in a diverse and multicultural environment.

 Accordingly, this certificate program is organized into three courses that build upon different levels of learning (knowledge, attitudes and skills).

 Best practices imply to increase awareness and knowledge but also develop opportunities for selfreflection, peer discussions and application in the clinical practice.

BEST PRACTICE GUIDELINES

To create the certificated training “Becoming Culturally Competent Providers” focused on providing integrated culturally competent inter-professional healthcare services to underserved populations.

PURPOSE

Key factors: Although many trainings in cultural competence are available, most of them are isolated and short courses targeted to a specific profession and/or focus only on awareness and knowledge instead of skills needed in clinical practice.

Problem: Changes in the demographics and diversity characteristics of the population show that we need to move beyond race/ethnicity to address the needs of diverse populations facing healthcare disparities. In order to address these disparities, healthcare providers need to provide culturally competent services to all their patient population.

BACKGROUND

Margarita Echeverri, PhD, MSc, Xavier University of Louisiana College of Pharmacy Ebony Gilbreath, DVM, PhD, DACVP, Tuskegee Veterinary Medicine Katherine Y. Brown, EdD, and Jacinta P. Leavell, MS, PhD, Meharry Medical College Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS)

Becoming Culturally Competent Healthcare Providers: A Prerequisite to Address Healthcare Disparities

• Despite the recognition of IV as a serious public health crisis by the Centers for Disease Control and Prevention (Dahlberg, 2009) , the US Surgeon General (Office of Surgeon General, 2001), the World Health Organization (Dahlberg & Krug, 2002), there has been little change in the training of medical students over the past 30 years about the effects of IV or how to screen for or address it.

• Children, adolescents, older adults, people who are exposed to poverty, discriminated due to race, ethnicity, persons who are LGBTQ, migrant farm workers, and persons experiencing homelessness are vulnerable to IV.

• IV includes child abuse, adolescent/youth violence, intimate partner violence, domestic violence, family violence, sexual violence, elder abuse, etc.

• Occurs as a single, intermittent or ongoing set of events which result in acute and chronic, physical and mental health injury, longterm disability, and death.

“The intentional use of physical force or power, threatened or actual, against another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, stunted emotional development, or deprivation”

• What is Interpersonal violence (IV)?

Background

CONCLUSIONS: Research findings suggest that teaching medical students about IV can have a positive impact on their knowledge, attitudes, and skills. Despite the known adverse effects of IV on the health and mental health of persons across the life course, the near universal support by medical and professional associations to address it, the evidence base for how to effectively address IV in the medical curriculum is still lacking.

RESULTS: A total of 29 articles were identified that sought to teach medical students how to respond to IV at different stages of the life course. Nineteen (65.5%) articles addressed domestic violence/intimate partner violence, four (13.8%) targeted sexual violence, three (10.3%) addressed child abuse, two (6.9%) addressed adolescent violence, and one (3.4%) examined family violence. One article identified IV as a health issue across the life course. Of the 29 studies, over half utilized a weak, non-experimental design and six utilized a strong quasi-experimental design.

METHODS: A systematic review of the literature was conducted using PRISMA guidelines to identify original studies that focused on how medical students are taught to address IV across the life course. An electronic search was conducted in MEDLINE/PubMed, PsycINFO, Web of Science, Scopus, Ingenta, Science Direct, and Google Scholar databases for articles in English published between March 2005 and February 2017. The search strategy cross-referenced keywords for interpersonal violence.

PURPOSE: Interpersonal violence (IV) is a leading cause of morbidity, disability, adverse mental health conditions, and mortality. Beyond both acute injuries and chronic conditions arising from IV, there is increasing recognition that IV can have long-term effects on the health and mental health of individuals due to physiological changes arising from exposure. However, without additional training, physicians are likely to encounter persons experiencing or at risk for interpersonal violence without recognizing or addressing it.

Abstract

• Quality ratings (QR): QR 1: Studies that used a non-experimental, qualitative or crosssectional design (low quality) QR 2: Studies that used a pre-test/post-test design only without a control group (weak quality) QR 3: QR 2 with a control group or a multiple time series design with no control group (moderately weak quality) QR 4: Studies that included a pre/post control design with a control group (strong quality)

• Quality Assessment.: Studies included in this review met the following criteria: (a) examined knowledge, attitudes, awareness and skills of medical student about IV, (b) presented primary data of an IV educational intervention (qualitative or quantitative) on screening, treatment, counseling, and referrals, (c) were published in English, (d) were conducted with students enrolled in an accredited US medical school, and (e) were published before February 2017.

• Data Extraction: sample (i.e., medical students by year); program format (i.e., readings, lectures, small group discussions, patient simulations or interviews); program targets (i.e., knowledge, comfort level, attitudes, screening, treatment, referrals); and a summary of key findings regarding program effectiveness.

• After screening, a total of 29 articles were identified that met the review criteria (Figure 1: PRISMA Flowchart).

• Exclusion Criteria: Articles that addressed IV interventions in residency training programs, other health professions training programs, health care provider continuing education, and articles that only recommended or described IV curriculum without implementation were excluded from the study.

• Search Criteria: Interpersonal violence, domestic violence, intimate partner violence, child abuse, sexual abuse, rape, elder abuse, bullying, youth violence, community violence, trauma AND medical education, medical curriculum, and medical students, AND prevention OR screening, OR care, OR treatment OR trauma informed care

• Inclusion Criteria: Studies included in this review met the following criteria: (a) examined knowledge, attitudes, awareness and skills of medical student about IV, (b) presented primary data of an IV educational intervention (qualitative or quantitative) on screening, treatment, counseling, and referrals, (c) were published in English, (d) were conducted with students enrolled in an accredited US medical school, and (e) were published before February 2017.

• An electronic search was conducted in different databases for articles in English published between March 2005 and February 2017. The search strategy cross-referenced keywords for interpersonal violence.

• A systematic review of the literature was conducted using PRISMA guidelines (Moher et al., 2009) to identify studies that focused on how medical students are taught to address IV across the life course.

Methods

• Identify the evidence base for the effectiveness of medical education in addressing IV among vulnerable populations.

• Identify the core medical education curricular elements that are used to address interpersonal violence.

• Identify the extent to which medical students are trained to screen, treat, or refer persons exposed to IV across the life course.

Goals

• IV can have long term effects on the health and mental health of individuals due to physiological changes that arise from the exposures. For e.g. exposure to IV can lead to PTSD as a result of physiological changes to the brain (Zannas et al., 2015; Moser et al., 2015).

• None of the studies examined impact of the intervention on patient outcomes.

• Studies that incorporated longer or multiple sessions as a part of their intervention were found to have positive results that also lasted over time, regardless of type of IV.

• Studies that incorporated interpersonal violence into medical education curriculum were found to be effective at increasing knowledge (Haist et al., 2003; Jonassen et al., 1997; Joyce et al., 2015; Pelletier & Knox, 2017), attitudes (Jonassen et al., 1997; Joyce et al., 2015; Milone et al., 2010) and skills (Haist et al., 2003; Jonassen et al., 1997; Joyce et al., 2015).

Key Findings

• A lecture or workshop was the most common teaching venue used; followed by a workshop or inter-clerkship designed to last more than eight hours but less than three days; an intervention that was spread across four days to two weeks; and an intervention that was incorporated as part of the longitudinal curriculum. Cross-sectional surveys administered without an organized intervention also were frequent.

• Sixteen (55.1%) of the studies had sample sizes of 100 or more, which includes one that targeted all students in an entire class and two (6.9%) that targeted all students in two or more classes.

• Seventeen (40.5%) of the articles targeted changes in knowledge about IV; fifteen (35.7%) aimed at changing attitudes or beliefs; five (11.9%) focused on changing level of awareness or comfort; and five (11.9%) targeted change in behavior or skills.

• Ten of the studies (34.5%) were published prior to 2000, eight (27.6%) between 2000 and 2010; and eleven (37.9%) between 2010 and 2017, demonstrating little change over time in attention given to IV.

• Nineteen (65.5%) of the articles addressed domestic violence or intimate partner violence, four of the articles (13.8%) targeted sexual violence, three (10.3%) addressed child abuse, two (6.9%) addressed adolescent violence, and one (3.4%) examined family violence.

Results

Figure 1: Schematic of PRISMA flowchart used for literature search.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UH1HP30348, entitled “Academic Units for Primary Care Training and Enhancement.” We also acknowledge the financial support provided by the NIH-RCMI grant (5U54MD00758633), which enabled us to present this work in the RCMI 2019 National Conference. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, NIH, HHS or the U.S. Government.

Acknowledgements

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(US) Office of the Surgeon General. Youth Violence: A report of the Surgeon General. In: NICIPC N, Center for Mental Health Services, ed. Rockville, MD: Office of the Surgeon General; 2001.

Pelletier HL, Knox M. Incorporating child maltreatment training into medical school curricula. Journ Child Adol Trauma. 2017;10(3):267274.

Moser DA, Paoloni-Giacobino A, Stenz L, et al. BDNF methylation and maternal brain activity in a violence-related sample. PLoS ONE. 2015;10(12):e0143427.

Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006-1012.

Milone JM, Burg MA, Duerson MC, Hagen MG, Pauly RR. The effect of lecture and a standardized patient encounter on medical student rape myth acceptance and attitudes toward screening patients for a history of sexual assault. Teaching and Learning in Medicine. 2010;22(1):37-44.

Knox M PH, Vieth V. Educating medical students about adolescent maltreatment. Int J Adolesc Med Health 2013;25(3): 301-308.

Joyce B, Jung D, C. Lucia V, Kavanagh M, Afonso N. Developing Medical Student Competence in Intimate Partner Violence: a National Priority. Vol 25 2015.

Jonassen JA, Doepel D, Pugnaire MP. An interclerkship course on domestic abuse. Academic Medicine. 1997;72(5):422-423.

Haist SA, Wilson JF, Pursley HG, et al. Domestic violence: increasing knowledge and improving skills with a four-hour workshop using standardized patients. Academic Medicine. 2003;78(10): S24-S26.

Dahlberg LL, Krug EG. Violence - a global public health problem. In: Dahlberg LL, & Krug, E. G, ed. Violence - a Global Public Health Problem. Geneva, Switzerland: World Health Organization; 2002:1– 56.

Dahlberg LL MJ. History of violence as a public health issue. AMA Virtual Mentor. 2009;11(2):167-172.

References

A Ramesh1; PD Juarez1; RL Cooper1; MJ Paul1; M Tabatabai1; TA Arcury2; M Shinn3; KY Brown1; W Im1; P Matthews-Juarez1

INTERVENTIONS TO TEACH INTERPERSONAL VIOLENCE TO MEDICAL STUDENTS

Selected Readings on Vulnerable Populations

5th Annual Communities of Practice Conference

2017 CONFERENCE

Selected Readings on Vulnerable Populations by Topics for Communities of Practice MEDICAL EDUCATION Ahrweiler, F., et al. (2014). “Clinical practice and self-awareness as determinants of empathy in undergraduate education: A qualitative short survey at three medical schools in Germany.” GMS Zeitschrift für Medizinische Ausbildung 31(4): Doc46. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4259065/

Akaike, M., et al. (2012). “Simulation-based medical education in clinical skills laboratory.” The Journal of Medical Investigation 59(1,2): 28-35.

El Rayess, F., et al. (2015). “Patient-Centered Medical Home Knowledge and Attitudes of Residents and Faculty: Certification Is Just the First Step.” Journal of Graduate Medical Education 7(4): 580-588. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4675415/

Hardeman, R. R., et al. (2015). “Medical student socio-demographic characteristics and attitudes toward patient centered care: Do race, socioeconomic status and gender matter? A report from the Medical Student CHANGES study.” Patient education and counseling 98(3): 350-355.

Banwari, G., et al. (2015). “Medical students and interns’ knowledge about and attitude towards homosexuality.” Journal of Postgraduate Medicine 61(2): 95-100.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4433154/

Brauer, D. G. and K. J. Ferguson (2015). “The integrated curriculum in medical education: AMEE Guide No. 96.” Medical teacher 37(4): 312-322.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4617779/

Burgess, D. J., et al. (2016). “Medical students’ learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from Medical Student CHANGES.” BMC Medical Education 16: 254.

http://www.tandfonline.com/doi/full/10.1080/10401334.2015.1108198

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943442/

http://www.tandfonline.com/doi/full/10.3109/0142159X.2014.970998

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5041316/

Davis, M. H. and R. M. Harden (2003). “Planning and implementing an undergraduate medical curriculum: the lessons learned.” Medical teacher 25(6): 596-608. http://www.tandfonline.com/doi/abs/10.1080/0142159032000144383

Harden, R. M. (2001). “AMEE Guide No. 21: Curriculum mapping: a tool for transparent and authentic teaching and learning.” Medical teacher 23(2): 123-137. http://www.tandfonline.com/doi/abs/10.1080/01421590120036547

Frank, E., et al. (2004). “Personal and clinical exercise-related attitudes and behaviors of freshmen U.S. medical students.” Research Quarterly for Exercise & Sport 75. http://www.tandfonline.com/doi/abs/10.1080/02701367.2004.10609142

Kiesewetter, J., et al. (2013). “Training of Leadership Skills in Medical Education.” GMS Zeitschrift für Medizinische Ausbildung 30(4): Doc49. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3839077/

Okuda, Y., et al. (2009). “The Utility of Simulation in Medical Education: What Is the Evidence?” Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine 76(4): 330-343. http://onlinelibrary.wiley.com/doi/10.1002/msj.20127/abstract

Przedworski, J. M., et al. (2015). “A Comparison of the Mental Health and Well-Being of Sexual Minority and Heterosexual First-Year Medical Students: A Report From Medical Student CHANGES.” Academic medicine : journal of the Association of American Medical Colleges 90(5): 652-659. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4414698/

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Rdesinski, R. E., et al. (2015). “Development and use of an instrument adapted to assess the clinical skills learning environment in the preclinical years.” Medical science educator 25(3): 285-291. To, M. J., et al. (2016). “Homelessness in the Medical Curriculum: An Analysis of Case-Based Learning Content From One Canadian Medical School.” Teaching and Learning in Medicine 28(1): 35-40. Wilcox, M. V., et al. (2017). “Medical students’ perceptions of the patient-centredness of the learning environment.” Perspectives on Medical Education 6(1): 44-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5285277/

Zick, A., et al. (2007). “First-year medical students’ assessment of their own communication skills: A video-based, open-ended approach.” Patient education and counseling 68(2): 161-166. http://www.sciencedirect.com/science/article/pii/S0738399107002236

5th Annual Communities of Practice Conference COMMUNITIES OF PRACTICE Barnett, S., et al. (2014). “Implementing a Virtual Community of Practice for Family Physician Training: A Mixed-Methods Case Study.” Journal of Medical Internet Research 16(3): e83. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3967123/

Cambridge D, K., S & Suter, V. (2005) Community of Practice Design GuideStep-by-Step Guide for Designing and Cultivating Communities of Practice https://net.educause.edu/ir/library/pdf/nli0531.pdf

Kimble, C., Hildreth, PM, & Bourdon, I (2008). Communities of practice: Creating learning environments for educators. Charlotte, NC, Omfpr,atopm Age {ib. Krug EG, D., LL, Mercy, JA, Zwi, AB, Lozano, R (2002). World report on violence and health. W. H. Organization. Geneva. Nasca, T. J. and I. Philibert (2009). “Communities of Practice and Learning: Disseminating Their Work.” Journal of Graduate Medical Education 1(1): 164-165. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2931189/

PG, H. C. K. (2005). “Using technology to transform communities of practice into knowledge-building communities.” SIGGROUP Bulletin 25(1): 31-40.

Selected Readings on Vulnerable Populations PRE-EXPOSURE PROPHYLAXIS (PREP) IN VULNERABLE POPULATIONS Pérez-Figueroa, R. E., et al. (2015). “ACCEPTABILITY OF PrEP UPTAKE AMONG RACIALLY/ETHNICALLY DIVERSE YOUNG MEN WHO HAVE SEX WITH MEN: THE P18 STUDY.” AIDS education and prevention : official publication of the International Society for AIDS Education 27(2): 112-125. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4550097/

Krakower, D. S. and K. H. Mayer (2015). “Pre-Exposure Prophylaxis to Prevent HIV Infection: Current Status, Future Opportunities and Challenges.” Drugs 75(3): 243-251. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4354703/

Kelley, C. F., et al. (2015). “Applying a PrEP Continuum of Care for Men Who Have Sex With Men in Atlanta, Georgia.” Clinical Infectious Diseases 61(10): 1590-1597. https://academic.oup.com/cid/article/61/10/1590/302887/Applying-a-PrEPContinuum-of-Care-for-Men-Who-Have

Golub, S. A., et al. (2013). “From Efficacy to Effectiveness: Facilitators and Barriers to PrEP Acceptability and Motivations for Adherence Among MSM and Transgender Women in New York City.” AIDS Patient Care and STDs 27(4): 248-254. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3624632/

Richardson, J. E., et al. (2015). “A needs assessment of health information technology for improving care coordination in three leading patient-centered medical homes.” Journal of the American Medical Informatics Association 22(4): 815-820.

Frankis, J., et al. (2016). “Who Will Use Pre-Exposure Prophylaxis (PrEP) and Why?: Understanding PrEP Awareness and Acceptability amongst Men Who Have Sex with Men in the UK – A Mixed Methods Study.” PLoS ONE 11(4): e0151385.

Roland, D., et al. (2017). “Preliminary Evidence for the Emergence of a Health Care Online Community of Practice: Using a Netnographic Framework for Twitter Hashtag Analytics.” J Med Internet Res 19(7): e252.

Deutsch, M. B., et al. (2015). “HIV pre-exposure prophylaxis in transgender women: a subgroup analysis of the iPrEx trial.” The Lancet HIV 2(12): e512-e519.

https://academic.oup.com/jamia/article-lookup/doi/10.1093/jamia/ocu039

http://www.jmir.org/2017/7/e252/

Saint-Onge, H., & Wallace, D (2003). Leveraging communities of practice for strategic advantage. Boston, MA, ButterworthHeinemann.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4836740/

http://www.sciencedirect.com/science/article/pii/S2352301815002064

Buchbinder, S. P., et al. (2014). “Who should be offered HIV preexposure prophylaxis (PrEP)?: A secondary analysis of a Phase 3 PrEP efficacy trial in men who have sex with men and transgender women.” The Lancet infectious diseases 14(6): 468-475. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4133171/

Soubhi, H., et al. (2010). “Learning and Caring in Communities of Practice: Using Relationships and Collective Learning to Improve Primary Care for Patients with Multimorbidity.” Annals of Family Medicine 8(2): 170-177. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2834724/

Walsh, K. and S. Barnett (2014). “Virtual Communities of Practice: Overcoming Barriers of Time and Technology.” J Med Internet Res 16(7): e185. http://www.jmir.org/2014/7/e185/

Welsh, S., Sherriff A, Flodgren G (2015) The champion for improved delivery of care to older people in long-term care settings: effects on professional practice, quality of care and resident outcomes. Cochrane Database of Systematic Reviews 11, http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011956/epdf

Wenger, E., McDermott, RA, & Snyder, W (2002). Cultivating communities of practice: A guide to managing knowlege. Boston, Harvard Business School Press.

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Selected Readings on Vulnerable Populations IMPLICIT BIAS Drewniak, D., et al. (2017). “Do attitudes and behavior of health care professionals exacerbate health care disparities among immigrant and ethnic minority groups? An integrative literature review.” International Journal of Nursing Studies 70: 89-98. http://www.sciencedirect.com/science/article/pii/S0020748917300494

FitzGerald, C. and S. Hurst (2017). “Implicit bias in healthcare professionals: a systematic review.” BMC Medical Ethics 18: 19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5333436/ Gonzalez, C. M., et al. (2014). “Implicit Bias and Its Relation to Health Disparities: A Teaching Program and Survey of Medical Students.” Teaching and Learning in Medicine 26(1): 64-71. http://www.tandfonline.com/doi/abs/10.1080/10401334.2013.857341

Jensen, N. M. (2014). “Physicians and Implicit Bias.” Journal of General Internal Medicine 29(5): 707-707. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4000338/

Jilani, D., et al. (2015). “Pre-clinical versus clinical medical students’ attitudes towards the poor in the United States.” Journal of Educational Evaluation for Health Professions 12: 52. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4671180/

Maina, I. W., et al. 2017 “A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test.” Social Science & Medicine. http://www.sciencedirect.com/science/article/pii/S0277953617303039

Paradies, Y., et al. (2014). “A Systematic Review of the Extent and Measurement of Healthcare Provider Racism.” Journal of General Internal Medicine 29(2): 364-387. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3912280/

Phelan, S. M., et al. (2015). “The mixed impact of medical school on medical students’ implicit and explicit weight bias.” Medical education 49(10): 983-992. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755318/

Sabin, J. A. and A. G. Greenwald (2012). “The Influence of Implicit Bias on Treatment Recommendations for 4 Common Pediatric Conditions: Pain, Urinary Tract Infection, Attention Deficit Hyperactivity Disorder, and Asthma.” American Journal of Public Health 102(5): 988-995. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483921/

Saha, S., et al. (2008). “Racial and Ethnic Disparities in the VA Health Care System: A Systematic Review.” Journal of General Internal Medicine 23(5): 654-671. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2324157/

Schiekirka, S., et al. (2014). “Assessment of two different types of bias affecting the results of outcome-based evaluation in undergraduate medical education.” BMC Medical Education 14: 149-149. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4112834/

van Ryn, M., et al. (2015). “Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report.” Journal of General Internal Medicine 30(12): 1748-1756. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4636581/

Williams, R. L., et al. (2015). “Racial, Gender, and Socioeconomic Status Bias in Senior Medical Student Clinical Decision-Making: A National Survey.” Journal of General Internal Medicine 30(6): 758-767. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4441663/

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5th Annual Communities of Practice Conference TEACHING MEDICAL AND DENTAL STUDENTS ABOUT VULNERABLE POPULATIONS LGBTQ Joan I. Anderson, D. D. S., April N. Patterson, D.D.S., Henry J. Temple, D.D.S. and Marita Rohr Inglehart, Dr. phil. habil. (2009). “Lesbian, Gay, Bisexual, and Transgender (LGBT) Issues in Dental School Environments: Dental Student Leaders’ Perceptions.” Journal of Dental Education 73(1): 105-118. Brondani MA1, P. R. (2011). “Teaching lesbian, gay, bisexual, and transgender issues in dental education: a multipurpose method.” J Dental Educ 75(10): 1354-1361. Corliss, H. L., et al. (2011). “High Burden of Homelessness Among Sexual-Minority Adolescents: Findings From a Representative Massachusetts High School Sample.” American Journal of Public Health 101(9): 1683-1689. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154237/

Cruz, T. M. (2014). “Assessing access to care for transgender and gender nonconforming people: A consideration of diversity in combating discrimination.” Social Science & Medicine 110: 65-73. http://www.sciencedirect.com/science/article/pii/S0277953614002111

Herman, T. N. T. B. a. J. L. (2015). INTIMATE PARTNER VIOLENCE AND SEXUAL ABUSE AMONG LGBT PEOPLE: A REVIEW OF EXISTING RESEARCH. Los Angeles, CA, The Williams Institute, UCLA School of Law https://williamsinstitute.law.ucla.edu/wp-content/uploads/IntimatePartner-Violence-and-Sexual-Abuse-among-LGBT-People.pdf

Keuroghlian, A. S., et al. (2014). “Out on the Street: A Public Health and Policy Agenda for Lesbian, Gay, Bisexual, and Transgender Youth Who Are Homeless.” The American journal of orthopsychiatry 84(1): 66-72. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4098056/

Poteat, T., et al. (2013). “Managing uncertainty: A grounded theory of stigma in transgender health care encounters.” Social Science & Medicine 84: 22-29. http://www.sciencedirect.com/science/article/pii/S0277953613001019

Roberts, T. K. and C. R. Fantz (2014). “Barriers to quality health care for the transgender population.” Clinical Biochemistry 47(10–11): 983-987. http://www.sciencedirect.com/science/article/pii/S0009912014000708

PERSONS EXPERIENCING HOMELESSNESS Edidin, J. P., et al. (2012). “The Mental and Physical Health of Homeless Youth: A Literature Review.” Child Psychiatry & Human Development 43(3): 354-375. https://link.springer.com/article/10.1007%2Fs10578-011-0270-1

Heerde, J. A., et al. (2015). “Associations Between Youth Homelessness, Sexual Offenses, Sexual Victimization, and Sexual Risk Behaviors: A Systematic Literature Review.” Archives of sexual behavior 44(1): 181-212. https://link.springer.com/article/10.1007%2Fs10508-014-0375-2

Keeshin, B. R. and K. Campbell (2011). “Screening homeless youth for histories of abuse: Prevalence, enduring effects, and interest in treatment.” Child Abuse & Neglect 35(6): 401-407. http://www.sciencedirect.com/science/article/pii/S0145213411001128

5th Annual Communities of Practice Conference Homelessness, N. C. o. F. (2013). The characteristics and needs of families experiencing homelessness. http://www.familyhomelessness.org/media/147.pdf

Vijayaraghavan, M., et al. (2012). “Health, Access to Health Care, and Health Care use Among Homeless Women with a History of Intimate Partner Violence.” Journal of community health 37(5): 1032-1039. https://link.springer.com/article/10.1007%2Fs10900-011-9527-7

Tyler, K. A., et al. (2004). “Risk Factors for Sexual Victimization Among Male and Female Homeless and Runaway Youth.” Journal of Interpersonal Violence 19(5): 503-520. http://journals.sagepub.com/doi/abs/10.1177/0886260504262961

To, M. J., et al. (2016). “Homelessness in the Medical Curriculum: An Analysis of Case-Based Learning Content From One Canadian Medical School.” Teaching and Learning in Medicine 28(1): 35-40. http://www.tandfonline.com/doi/full/10.1080/10401334.2015.1108198

Rafferty, Y. S., Marybeth (1991). “The impact of homelessness on children.” American Psychologist 46(11): 1170-1179. Kilmer, R. P. C., James R.; Crusto, Cindy; Strater, Katherine P.; Haber, Mason G. (2012). “Understanding the ecology and development of children and families experiencing homelessness: Implications for practice, supportive services, and policy. .” American Journal of Orthopsychiatry 82(3): 389-401. Vijayaraghavan, M., et al. (2012). “Health, Access to Health Care, and Health Care use Among Homeless Women with a History of Intimate Partner Violence.” Journal of community health 37(5): 1032-1039.

Selected Readings on Vulnerable Populations ADVERSE CHILDHOOD EXPERIENCES Anda, R., Felitti, VJ, Walker, J, Whit, CL (2006). “The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology.” European Archives of Psychiatry and Clinical Neurosciences 256(3): 174-186. Andersen, J. P., et al. (2015). “Multiple early victimization experiences as a pathway to explain physical health disparities among sexual minority and heterosexual individuals.” Social Science & Medicine 133: 111-119. http://www.sciencedirect.com/science/article/pii/S0277953615001963

Brown, M. J., et al. (2015). “Sex and sexual orientation disparities in adverse childhood experiences and early age at sexual debut in the United States: Results from a nationally representative sample().” Child Abuse & Neglect 46: 89-102. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527947/

Brown, M. J., et al. (2015). “Adverse childhood experiences and intimate partner aggression in the US: Sex differences and similarities in psychosocial mediation.” Social science & medicine (1982) 131: 48-57. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4479130/

Danese, A., et al. (2007). “Childhood maltreatment predicts adult inflammation in a life-course study.” Proceedings of the National Academy of Sciences 104(4): 1319-1324.

MIGRANT FARM WORKERS

Dube, S. R., et al. (2001). “Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study.” JAMA 286(24): 3089-3096.

Human Rights Watch, (2012). “Cultivating fear: the vulnerability of immigrant farm workers in the US to sexual violence and sexual harassment. Human Rights Watch Report.”

Felitti, V. J., et al. (1998). “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults.” American Journal of Preventive Medicine 14(4): 245-258.

https://www.hrw.org/report/2012/05/15/cultivating-fear/

http://www.sciencedirect.com/science/article/pii/S0749379798000178

Meng, G. (May 5 2012). “The Vulnerability of Immigrant Farmworkers in the US to Sexual Violence and Sexual Harassment.”

Herman, D. B., et al. (1997). “Adverse childhood experiences: are they risk factors for adult homelessness?” American Journal of Public Health 87(2): 249-255.

https://link.springer.com/article/10.1007%2Fs10900-011-9527-7

https://www.hrw.org/report/2012/05/15/cultivating-fear/vulnerabilityimmigrant-farmworkers-us-sexual-violence-and-sexual

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380802/

R, R. (1998). Clinical interventions with battered migrant farm worker women. Empowering Survivors of Abuse: Health Care for Battered Women and their Children. e. Campbell JC. Thousand Oaks, CA, Sage: 271-279.

Huang, H., et al. (2015). “Adverse childhood experiences and risk of type 2 diabetes: A systematic review and meta-analysis.” Metabolism 64(11): 1408-1418.

Wilson, J. B., et al. (2014). “Intimate Partner Violence Screening Among Migrant/Seasonal Farmworker Women and Healthcare: A Policy Brief.” Journal of community health 39(2): 372-377.

Meyer, I. H. (2003). “Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence.” Psychological bulletin 129(5): 674-697.

https://link.springer.com/article/10.1007%2Fs10900-013-9772-z

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2072932/

Van Hightower, N. R., et al. (2000). “Predictive Models of Domestic Violence and Fear of Intimate Partners Among Migrant and Seasonal Farm Worker Women.” Journal of Family Violence 15(2): 137-154.

Korotana, L. M., et al. (2016). “A review of primary care interventions to improve health outcomes in adult survivors of adverse childhood experiences.” Clinical Psychology Review 46: 59-90.

https://link.springer.com/article/10.1023%2FA%3A1007538810858

http://www.sciencedirect.com/science/article/pii/S0026049515002528

http://www.sciencedirect.com/science/article/pii/S0272735815300295

Krause, K. D., et al. (2016). “Early Life Psychosocial Stressors and Housing Instability among Young Sexual Minority Men: the P18 Cohort Study.” Journal of Urban Health : Bulletin of the New York Academy of Medicine 93(3): 511-525. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4899333/

Nemeroff, C. B. (2004). “Neurobiological consequences of childhood trauma.” The Journal of clinical psychiatry.

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Nurius, P. S., et al. (2012). “ACEs within a Social Disadvantage Framework: Distinguishing Unique, Cumulative, and Moderated Contributions to Adult Mental Health.” J Prev Interv Community 40(4): 278-290.

Jonassen, J. A. and K. M. Mazor (2003). “Identification of Physician and Patient Attributes That Influence the Likelihood of Screening for Intimate Partner Violence.” Academic Medicine 78(10): S20-S23.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445037/

http://journals.lww.com/academicmedicine/Fulltext/2003/10001/ Identification_of_Physician_and_Patient_Attributes.7.aspx

Patterson, M. L., et al. (2014). “Setting the stage for chronic health problems: cumulative childhood adversity among homeless adults with mental illness in Vancouver, British Columbia.” BMC Public Health 14: 350-350.

Martin-Storey, A. (2015). “Prevalence of Dating Violence Among Sexual Minority Youth: Variation Across Gender, Sexual Minority Identity and Gender of Sexual Partners.” Journal of youth and adolescence 44(1): 211-224.

Roos, L. E., et al. (2013). “Relationship Between Adverse Childhood Experiences and Homelessness and the Impact of Axis I and II Disorders.” American Journal of Public Health 103(Suppl 2): S275-S281.

Moracco, K. E., et al. (2005). “Knowledge and Attitudes About Intimate Partner Violence Among Immigrant Latinos in Rural North Carolina.” Violence Against Women 11(3): 337-352.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3991866/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3969113/

Schneeberger, A. R., et al. (2014). “Stressful childhood experiences and health outcomes in sexual minority populations: a systematic review.” Soc Psychiatry Psychiatr Epidemiol 49(9): 1427-1445. https://link.springer.com/article/10.1007%2Fs00127-014-0854-8

Vernon-Feagans, L., Cox, M. J., & Conger, R. (2013). The family life project: An epidemiological and developmental study of young children living in poor rural communities. Boston, MA, Wiley. Zou, C. and J. P. Andersen (2015). “Comparing the Rates of Early Childhood Victimization across Sexual Orientations: Heterosexual, Lesbian, Gay, Bisexual, and Mostly Heterosexual.” PLoS ONE 10(10): e0139198. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596800/

INTERPERSONAL VIOLENCE ACROSS THE LIFESPAN Anderson, M. J. (1993). “A license to abuse: The impact of conditional status on female immigrants.” The Yale Law Journal 102(6): 14011430. Balsam KF, R. E., Beauchaine TP. (2005). “Victimization over the life span: a comparison of lesbian, gay, bisexual, and heterosexual siblings.” J Consult and Clinical Psych. 73(3): 477-487. Chen, P.-H., et al. (2005). “Screening for domestic violence in a predominantly Hispanic clinical setting.” Family Practice 22(6): 617623. https://academic.oup.com/fampra/article-lookup/doi/10.1093/fampra/ cmi075

Corliss, H. L., et al. (2002). “Reports of parental maltreatment during childhood in a United States population-based survey of homosexual, bisexual, and heterosexual adults().” Child Abuse & Neglect 26(11): 1165-1178. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194076/

Edwards, K. M., Sylaska, K. M., & Neal, A. M. (2015). “Intimate Partner Violence among Sexual Minority Populations: A Critical Review of the Literature and Agenda for Future Research.” Psychology of Violence, 5(2): 112-121. Earnshaw, V. A., et al. (2016). “Bullying Among Lesbian, Gay, Bisexual, and Transgender Youth.” Pediatric Clinics of North America 63(6): 999-1010. http://www.sciencedirect.com/science/article/pii/S0031395516410564

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https://link.springer.com/article/10.1007%2Fs10964-013-0089-0

http://journals.sagepub.com/doi/10.1177/1077801204273296

Murray, C. E., et al. (2007). “Same-sex intimate partner violence: Dynamics, social context, and counseling implications.” Journal of LGBT Issues in Counseling 1(4): 7-30. Ramsay, J., et al. (2002). “Should health professionals screen women for domestic violence? Systematic review.” BMJ 325(7359): 314. http://www.bmj.com/content/bmj/325/7359/314.full.pdf

Rothman, E. F., et al. (2011). “The prevalence of sexual assault against people who identify as gay, lesbian, or bisexual in the United States: A systematic review.” Trauma, Violence, & Abuse 12(2): 55-66. Tjaden P1, T. N., Allison CJ. (1999). “Comparing violence over the life span in samples of same-sex and opposite-sex cohabitants.” Violence Vict. 14(4): 413-425. Walters, M. L., Chen J., & Breiding, M.J (2013). The National Intimate Partner and Sexual Violence Survey 2010 Findings on Victimization by Sexual Orientation National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention https://www.cdc.gov/violenceprevention/pdf/nisvs_sofindings.pdf

West, C. M. (2012). “Partner Abuse in Ethnic Minority and Gay, Lesbian, Bisexual, and Transgender Populations.” Partner Abuse 3(3): 336-357. http://www.ingentaconnect.com/content/springer/ pa/2012/00000003/00000003/art00003

Whitton, S. W., et al. (2016). “A Longitudinal Study of IPV Victimization Among Sexual Minority Youth.” Journal of Interpersonal Violence: 0886260516646093. http://journals.sagepub.com/doi/10.1177/0886260516646093

Widom, C. S., et al. (2014). “Child Abuse and Neglect and Intimate Partner Violence Victimization and Perpetration: A Prospective Investigation.” Child Abuse & Neglect 38(4): 650-663. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4035378/

Zou, C. and J. P. Andersen (2015). “Comparing the Rates of Early Childhood Victimization across Sexual Orientations: Heterosexual, Lesbian, Gay, Bisexual, and Mostly Heterosexual.” PLoS ONE 10(10): e0139198. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596800/

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2018 CONFERENCE

Selected Readings on Vulnerable Populations by Topics for Communities of Practice ADVERSE CHILDHOOD EXPERIENCES LGBTQ Andersen, J. P., & Blosnich, J. (2013). Disparities in Adverse Childhood Experiences among Sexual Minority and Heterosexual Adults: Results from a Multi-State Probability-Based Sample. PLoS ONE, 8(1), e54691. doi:10.1371/journal.pone.0054691 https://www.ncbi.nlm.nih.gov/pubmed/23372755

Andersen, J. P., Zou, C., & Blosnich, J. (2015). Multiple early victimization experiences as a pathway to explain physical health disparities among sexual minority and heterosexual individuals. Soc Sci Med, 133, 111-119. doi:10.1016/j.socscimed.2015.03.043 https://doi.org/10.1016/j.socscimed.2015.03.043

Austin, A., Herrick, H., & Proescholdbell, S. (2016). Adverse Childhood Experiences Related to Poor Adult Health Among Lesbian, Gay, and Bisexual Individuals. Am J Public Health, 106(2), 314-320. doi:10.2105/ ajph.2015.302904

Zou, C., & Andersen, J. P. (2015). Comparing the Rates of Early Childhood Victimization across Sexual Orientations: Heterosexual, Lesbian, Gay, Bisexual, and Mostly Heterosexual. PLoS ONE, 10(10), e0139198. doi:10.1371/journal.pone.0139198 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596800/

PERSONS EXPERIENCING HOMELESSNESS Herman, D. B., Susser, E. S., Struening, E. L., & Link, B. L. (1997). Adverse childhood experiences: are they risk factors for adult homelessness? American Journal of Public Health, 87(2), 249-255. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380802/

Murphy, A., Steele, H., Bate, J., Nikitiades, A., Allman, B., Bonuck, K., . . . Steele, M. (2015). Group attachment-based intervention: trauma-informed care for families with adverse childhood experiences. Fam Community Health, 38(3), 268-279. doi:10.1097/ fch.0000000000000074

https://ajph.aphapublications.org/doi/10.2105/AJPH.2015.302904

https://www.researchgate.net/publication/277411530_Group_AttachmentBased_Intervention_Trauma-Informed_Care_for_Families_With_Adverse_ Childhood_Experiences

Blosnich, J. R., & Andersen, J. P. (2015). Thursday’s child: the role of adverse childhood experiences in explaining mental health disparities among lesbian, gay, and bisexual U.S. adults. Soc Psychiatry Psychiatr Epidemiol, 50(2), 335-338. doi:10.1007/s00127014-0955-4

Patterson, M. L., Moniruzzaman, A., & Somers, J. M. (2014). Setting the stage for chronic health problems: cumulative childhood adversity among homeless adults with mental illness in Vancouver, British Columbia. BMC Public Health, 14, 350-350. doi:10.1186/1471-2458-14350

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4512235/

Clements-Nolle, K., Lensch, T., Baxa, A., Gay, C., Larson, S., & Yang, W. (2018). Sexual Identity, Adverse Childhood Experiences, and Suicidal Behaviors. J Adolesc Health, 62(2), 198-204. doi:10.1016/j. jadohealth.2017.09.022 https://www.ncbi.nlm.nih.gov/pubmed/25936843

McLaughlin, K. A., Hatzenbuehler, M. L., Xuan, Z., & Conron, K. J. (2012). Disproportionate Exposure to Early-Life Adversity and Sexual Orientation Disparities in Psychiatric Morbidity. Child Abuse & Neglect, 36(9), 645-655. doi:10.1016/j.chiabu.2012.07.004

https://bmcpublichealth.biomedcentral.com/ articles/10.1186/1471-2458-14-350

Roos, L. E., Mota, N., Afifi, T. O., Katz, L. Y., Distasio, J., & Sareen, J. (2013). Relationship between adverse childhood experiences and homelessness and the impact of axis I and II disorders. Am J Public Health, 103 Suppl 2, S275-281. doi:10.2105/ajph.2013.301323 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3969113/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445753/

To, M. J., MacLeod, A., & Hwang, S. W. (2016). Homelessness in the Medical Curriculum: An Analysis of Case-Based Learning Content From One Canadian Medical School. Teaching and Learning in Medicine, 28(1), 35-40. doi:10.1080/10401334.2015.1108198

Meyer, I. H. (2003). Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychological bulletin, 129(5), 674-697. doi:10.1037/0033-2909.129.5.674

Tsai, J., & Rosenheck, R. A. (2015). Risk Factors for Homelessness Among US Veterans. Epidemiologic reviews, 37, 177-195. doi:10.1093/ epirev/mxu004

https://www.ncbi.nlm.nih.gov/pubmed/26787083

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2072932/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4521393/

Ports, K. A., Lee, R. D., Raiford, J., Spikes, P., Manago, C., & Wheeler, D. P. (2017). Adverse Childhood Experiences and Health and Wellness Outcomes among Black Men Who Have Sex with Men. J Urban Health, 94(3), 375-383. doi:10.1007/s11524-017-0146-1

MIGRANT FARM WORKERS

https://www.ncbi.nlm.nih.gov/pubmed/28321794

Schneeberger, A. R., Dietl, M. F., Muenzenmaier, K. H., Huber, C. G., & Lang, U. E. (2014). Stressful childhood experiences and health outcomes in sexual minority populations: a systematic review. Soc Psychiatry Psychiatr Epidemiol, 49(9), 1427-1445. doi:10.1007/s00127014-0854-8

Loria, H., & Caughy, M. (2018). Prevalence of Adverse Childhood Experiences in Low-Income Latino Immigrant and Nonimmigrant Children. J Pediatr, 192, 209-215.e201. doi:10.1016/j.jpeds.2017.09.056 https://www.deepdyve.com/lp/elsevier/prevalence-of-adverse-childhoodexperiences-in-low-income-latino-aySkxgYgy6

Migrant Clinicians Network. Toxic Stress.

https://www.migrantclinician.org/blog/2018/may/toxic-stress.html

https://link.springer.com/article/10.1007/s00127-014-0854-8

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Selected Readings on Vulnerable Populations MEDICAL EDUCATION Albaek, A. U., Kinn, L. G., & Milde, A. M. (2018). Walking Children Through a Minefield: How Professionals Experience Exploring Adverse Childhood Experiences. Qual Health Res, 28(2), 231-244. doi:10.1177/1049732317734828 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734381/

Balistreri, K. S. (2015). Adverse Childhood Experiences, the Medical Home, and Child Well-Being. Matern Child Health J, 19(11), 2492-2500. doi:10.1007/s10995-015-1770-6 Brody, G. H., Yu, T., Chen, E., & Miller, G. E. (2017). Family-centered prevention ameliorates the association between adverse childhood experiences and prediabetes status in young black adults. Prev Med, 100, 117-122. doi:10.1016/j.ypmed.2017.04.017 https://www.ncbi.nlm.nih.gov/pubmed/28431967

Conn, A. M., Szilagyi, M. A., Jee, S. H., Manly, J. T., Briggs, R., & Szilagyi, P. G. (2017). Parental Perspectives of Screening for Adverse Childhood Experiences in Pediatric Primary Care. Fam Syst Health. doi:10.1037/fsh0000311 https://www.ncbi.nlm.nih.gov/pubmed/29215906

Felitti Md FVJ, Anda Md MSRF, Nordenberg Md D, et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine. 1998;14(4):245-258.

5th Annual Communities of Practice Conference Kerker, B. D., Storfer-Isser, A., Szilagyi, M., Stein, R. E., Garner, A. S., O’Connor, K. G., . . . Horwitz, S. M. (2016). Do Pediatricians Ask About Adverse Childhood Experiences in Pediatric Primary Care? Acad Pediatr, 16(2), 154-160. doi:10.1016/j.acap.2015.08.002 https://www.aap.org/en-us/Documents/journals_research_update.pdf

Korotana, L. M., Dobson, K. S., Pusch, D., & Josephson, T. (2016). A review of primary care interventions to improve health outcomes in adult survivors of adverse childhood experiences. Clin Psychol Rev, 46, 59-90. doi:10.1016/j.cpr.2016.04.007 https://www.sciencedirect.com/science/article/pii/S0272735815300295

Magen, E., & DeLisser, H. M. (2017). Best Practices in Relational Skills Training for Medical Trainees and Providers: An Essential Element of Addressing Adverse Childhood Experiences and Promoting Resilience. Acad Pediatr, 17(7s), S102-s107. doi:10.1016/j. acap.2017.03.006 https://www.sciencedirect.com/science/article/pii/S1876285917301067

Marie-Mitchell, A., Studer, K. R., & O’Connor, T. G. (2016). How knowledge of adverse childhood experiences can help pediatricians prevent mental health problems. Fam Syst Health, 34(2), 128135. doi:10.1037/fsh0000179 https://www.researchgate.net/ publication/297593700_How_Knowledge_of_Adverse_Childhood_ Experiences_Can_Help_Pediatricians_Prevent_Mental_Health_ Problems

https://www.ncbi.nlm.nih.gov/pubmed/9635069

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Flynn, A. B., Fothergill, K. E., Wilcox, H. C., Coleclough, E., Horwitz, R., Ruble, A., . . . Wissow, L. S. (2015). Primary Care Interventions to Prevent or Treat Traumatic Stress in Childhood: A Systematic Review. Acad Pediatr, 15(5), 480-492. doi:10.1016/j.acap.2015.06.012

McKelvey, L. M., Selig, J. P., & Whiteside-Mansell, L. (2017). Foundations for screening adverse childhood experiences: Exploring patterns of exposure through infancy and toddlerhood. Child Abuse Negl, 70, 112-121. doi:10.1016/j.chiabu.2017.06.002

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Montalvo-Liendo, N., Fredland, N., McFarlane, J., Lui, F., Koci, A. F., & Nava, A. (2015). The Intersection of Partner Violence and Adverse Childhood Experiences: Implications for Research and Clinical Practice. Issues Ment Health Nurs, 36(12), 989-1006. doi:10.3109/01612 840.2015.1074767

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5th Annual Communities of Practice Conference Szilagyi, M., Kerker, B. D., Storfer-Isser, A., Stein, R. E., Garner, A., O’Connor, K. G., . . . McCue Horwitz, S. (2016). Factors Associated With Whether Pediatricians Inquire About Parents’ Adverse Childhood Experiences. Acad Pediatr, 16(7), 668-675. doi:10.1016/j. acap.2016.04.013

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Traub, F., & Boynton-Jarrett, R. (2017). Modifiable Resilience Factors to Childhood Adversity for Clinical Pediatric Practice. Pediatrics, 139(5). doi:10.1542/peds.2016-2569 http://pediatrics.aappublications.org/content/early/2017/04/17/peds.20162569

Vega-Arce, M., & Nunez-Ulloa, G. (2017). [Screening of adverse childhood experiences in preschoolers: scoping review]. Bol Med Hosp Infant Mex, 74(6), 385-396. doi:10.1016/j.bmhimx.2017.07.003 https://www.sciencedirect.com/science/article/pii/ S1665114617300989?via%3Dihub

Wade, R., Jr., Becker, B. D., Bevans, K. B., Ford, D. C., & Forrest, C. B. (2017). Development and Evaluation of a Short Adverse Childhood Experiences Measure. Am J Prev Med, 52(2), 163-172. doi:10.1016/j. amepre.2016.09.033 https://www.sciencedirect.com/science/article/pii/ S0749379716304998?via%3Dihub

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Cohen, J. A., Mannarino, A. P., & Murray, L. K. (2011). Traumafocused CBT for youth who experience ongoing traumas. Child Abuse & Neglect, 35(8), 637-646. doi:http://dx.doi.org/10.1016/j. chiabu.2011.05.002 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3171639/

Ellis, W. R., & Dietz, W. H. (2017). A New Framework for Addressing Adverse Childhood and Community Experiences: The Building Community Resilience Model. Acad Pediatr, 17(7s), S86-s93. doi:10.1016/j.acap.2016.12.011

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Finkelhor, D., Shattuck, A., Turner, H., & Hamby, S. (2015). A revised inventory of Adverse Childhood Experiences. Child Abuse Negl, 48, 13-21. doi:10.1016/j.chiabu.2015.07.011 https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S01452134150 02409?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii %2FS0145213415002409%3Fshowall%3Dtrue&referrer=https:%2F%2F www.ncbi.nlm.nih.gov%2F

Green, B. L., Saunders, P. A., Power, E., Dass-Brailsford, P., Schelbert, K. B., Giller, E., . . . Mete, M. (2015). Trauma-Informed Medical Care: A CME Communication Training for Primary Care Providers. Family medicine, 47(1), 7-14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4316735/

Leitch, L. (2017). Action steps using ACEs and trauma-informed care: a resilience model. Health Justice, 5(1), 5. doi:10.1186/s40352-0170050-5 https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352017-0050-5

Marsac, M. L., Kassam-Adams, N., Hildenbrand, A. K., Nicholls, E., Winston, F. K., Leff, S. S., & Fein, J. (2016). Implementing a TraumaInformed Approach in Pediatric Healthcare Networks. JAMA Pediatrics, 170(1), 70-77. doi:10.1001/jamapediatrics.2015.2206 https://jamanetwork.com/journals/jamapediatrics/fullarticle/2470861

Oral, R., Ramirez, M., Coohey, C., Nakada, S., Walz, A., Kuntz, A., . . . Peek-Asa, C. (2016). Adverse childhood experiences and trauma informed care: the future of health care. Pediatr Res, 79(1-2), 227-233. doi:10.1038/pr.2015.197 https://www.nature.com/articles/pr2015197

Pachter, L. M., Lieberman, L., Bloom, S. L., & Fein, J. A. (2017). Developing a Community-Wide Initiative to Address Childhood Adversity and Toxic Stress: A Case Study of The Philadelphia ACE Task Force. Acad Pediatr, 17(7s), S130-s135. doi:10.1016/j.acap.2017.04.012 https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S18762859173 01687?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii %2FS1876285917301687%3Fshowall%3Dtrue&referrer=https:%2F%2F www.ncbi.nlm.nih.gov%2F

Raja, S., Hoersch, M., Rajagopalan, C. F., & Chang, P. (2014). Treating patients with traumatic life experiences: Providing trauma-informed care. The Journal of the American Dental Association, 145(3), 238245. doi:https://doi.org/10.14219/jada.2013.30 https://www.sciencedirect.com/science/article/pii/ S0002817714600593?via%3Dihub

Schilling, S., Fortin, K., & Forkey, H. (2015). Medical Management and Trauma-Informed Care for Children in Foster Care. Current Problems in Pediatric and Adolescent Health Care, 45(10), 298-305. doi:http:// dx.doi.org/10.1016/j.cppeds.2015.08.004

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Sperlich, M., Seng, J. S., Li, Y., Taylor, J., & Bradbury-Jones, C. (2017). Integrating Trauma-Informed Care Into Maternity Care Practice: Conceptual and Practical Issues. J Midwifery Womens Health, 62(6), 661-672. doi:10.1111/jmwh.12674 https://onlinelibrary.wiley.com/doi/abs/10.1111/jmwh.12674

Weinstein, Wolin, & Rose. (2014). Trauma Informed Community Building A Model for Strengthening Community in Trauma Affected Neighborhoods. https://healthequity.sfsu.edu/content/white-paper-model-strengtheningcommunity-trauma-affected-neighborhoods

INTERPERSONAL VIOLENCE ACROSS THE LIFE COURSE LGBTQ Ard, K. L., & Makadon, H. J. (2011). Addressing Intimate Partner Violence in Lesbian, Gay, Bisexual, and Transgender Patients. Journal of General Internal Medicine, 26(8), 930-933. doi:10.1007/s11606-0111697-6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3138983/

Baker, N. L., Buick, J. D., Kim, S. R., Moniz, S., & Nava, K. L. (2013). Lessons from Examining Same-Sex Intimate Partner Violence. Sex Roles, 69(3), 182-192. doi:10.1007/s11199-012-0218-3 https://link.springer.com/article/10.1007%2Fs11199-012-0218-3

Balsam, K. F., Rothblum, E. D., & Beauchaine, T. P. (2005). Victimization Over the Life Span: A Comparison of Lesbian, Gay, Bisexual, and Heterosexual Siblings. Journal of Consulting and Clinical Psychology, 73(3), 477-487. doi:10.1037/0022-006X.73.3.477 http://psycnet.apa.org/doiLanding?doi=10.1037%2F0022-006X.73.3.477

Blain, L. M., Muench, F., Morgenstern, J., & Parsons, J. T. (2012). Exploring the role of child sexual abuse and posttraumatic stress disorder symptoms in gay and bisexual men reporting compulsive sexual behavior. Child Abuse & Neglect, 36(5), 413-422. doi:http:// dx.doi.org/10.1016/j.chiabu.2012.03.003 https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S01452134120 00774?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii %2FS0145213412000774%3Fshowall%3Dtrue&referrer=https:%2F%2F www.ncbi.nlm.nih.gov%2F

Burke, T. W., Jordan, M. L., & Owen, S. S. (2002). A cross-national comparison of gay and lesbian domestic violence. Journal of Contemporary Criminal Justice, 18(3), 231-257. http://journals.sagepub.com/doi/ abs/10.1177/1043986202018003003?journalCode=ccja

Corliss, H. L., Cochran, S. D., & Mays, V. M. (2002). Reports of parental maltreatment during childhood in a United States population-based survey of homosexual, bisexual, and heterosexual adults(). Child Abuse & Neglect, 26(11), 1165-1178. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194076/

Dank, M., Lachman, P., Zweig, J. M., & Yahner, J. (2014). Dating Violence Experiences of Lesbian, Gay, Bisexual, and Transgender Youth. Journal of youth and adolescence, 43(5), 846-857. doi:10.1007/ s10964-013-9975-8 https://link.springer.com/article/10.1007%2Fs10964-013-9975-8

Earnshaw, V. A., Bogart, L. M., Poteat, V. P., Reisner, S. L., & Schuster, M. A. (2016). Bullying Among Lesbian, Gay, Bisexual, and Transgender Youth. Pediatric Clinics of North America, 63(6), 999-1010. doi:http:// dx.doi.org/10.1016/j.pcl.2016.07.004

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Elze, D. E. (2003). Gay, lesbian, and bisexual youths’ perceptions of their high school environments and comfort in school. Children & Schools, 25(4), 225-239.

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Frankland, A., & Brown, J. (2014). Coercive Control in Same-Sex Intimate Partner Violence. Journal of Family Violence, 29(1), 15-22. doi:10.1007/s10896-013-9558-1 https://link.springer.com/article/10.1007/s10896-013-9558-1

Freedner, N., Freed, L. H., Yang, Y. W., & Austin, S. B. (2002). Dating violence among gay, lesbian, and bisexual adolescents: results from a community survey. Journal of Adolescent Health, 31(6), 469-474. doi:http://dx.doi.org/10.1016/S1054-139X(02)00407-X https://www.ncbi.nlm.nih.gov/pubmed/12457580

Han, S. C., Gallagher, M. W., Franz, M. R., Chen, M. S., Cabral, F. M., & Marx, B. P. (2013). Childhood Sexual Abuse, Alcohol Use, and PTSD Symptoms as Predictors of Adult Sexual Assault Among Lesbians and Gay Men. Journal of Interpersonal Violence, 28(12), 2505-2520. doi:10.1177/0886260513479030 http://journals.sagepub.com/doi/ abs/10.1177/0886260513479030?journalCode=jiva

Heintz, A. J., & Melendez, R. M. (2006). Intimate Partner Violence and HIV/STD Risk Among Lesbian, Gay, Bisexual, and Transgender Individuals. Journal of Interpersonal Violence, 21(2), 193-208. doi:10.1177/0886260505282104 http://journals.sagepub.com/doi/abs/10.1177/0886260505282104

Hughes, T., McCabe, S. E., Wilsnack, S. C., West, B. T., & Boyd, C. J. (2010). Victimization and substance use disorders in a national sample of heterosexual and sexual minority women and men. Addiction (Abingdon, England), 105(12), 2130-2140. doi:10.1111/j.13600443.2010.03088.x https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3006226/

Kosciw, J. G., Greytak, E. A., & Diaz, E. M. (2009). Who, What, Where, When, and Why: Demographic and Ecological Factors Contributing to Hostile School Climate for Lesbian, Gay, Bisexual, and Transgender Youth. Journal of youth and adolescence, 38(7), 976-988. doi:10.1007/ s10964-009-9412-1 https://link.springer.com/article/10.1007%2Fs10964-009-9412-1

McKenry, P. C., Serovich, J. M., Mason, T. L., & Mosack, K. (2006). Perpetration of gay and lesbian partner violence: A disempowerment perspective. Journal of Family Violence, 21(4), 233-243. https://link.springer.com/article/10.1007%2Fs10896-006-9020-8

Murray, C. E., Mobley, A. K., Buford, A. P., & Seaman-DeJohn, M. M. (2007). Same-sex intimate partner violence: Dynamics, social context, and counseling implications. Journal of LGBT Issues in Counseling, 1(4), 7-30. https://libres.uncg.edu/ir/uncg/f/AK_Mobley_Same_2007.pdf

Pilkington, N. W., & D’Augelli, A. R. (1995). Victimization of lesbian, gay, and bisexual youth in community settings. Journal of Community Psychology, 23(1), 34-56. https://onlinelibrary.wiley.com/doi/full/10.1002/15206629%28199501%2923%3A1%3C34%3A%3AAID-

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Roberts, A. L., Austin, S. B., Corliss, H. L., Vandermorris, A. K., & Koenen, K. C. (2010). Pervasive Trauma Exposure Among US Sexual Orientation Minority Adults and Risk of Posttraumatic Stress Disorder. American Journal of Public Health, 100(12), 2433-2441. doi:10.2105/AJPH.2009.168971

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Petering, R., Rhoades, H., Winetrobe, H., Dent, D., & Rice, E. (2017). Violence, Trauma, Mental Health, and Substance Use Among Homeless Youth Juggalos. Child Psychiatry & Human Development, 48(4), 642-650. doi:10.1007/s10578-016-0689-5

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Rothman, E. F., Exner, D., & Baughman, A. L. (2011). The prevalence of sexual assault against people who identify as gay, lesbian, or bisexual in the United States: A systematic review. Trauma, Violence, & Abuse, 12(2), 55-66.

Petering, R., Rice, E., Rhoades, H., & Winetrobe, H. (2014). The Social Networks of Homeless Youth Experiencing Intimate Partner Violence. Journal of Interpersonal Violence, 29(12), 2172-2191. doi:10.1177/0886260513516864

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West, C. M. (2012). Partner Abuse in Ethnic Minority and Gay, Lesbian, Bisexual, and Transgender Populations. Partner Abuse, 3(3), 336-357. doi:10.1891/1946-6560.3.3.336

Ponce, A. N., Lawless, M. S., & Rowe, M. (2014). Homelessness, Behavioral Health Disorders and Intimate Partner Violence: Barriers to Services for Women. Community Mental Health Journal, 50(7), 831-840. doi:10.1007/s10597-014-9712-0

Whitton, S. W., Newcomb, M. E., Messinger, A. M., Byck, G., & Mustanski, B. (2016). A Longitudinal Study of IPV Victimization Among Sexual Minority Youth. Journal of Interpersonal Violence, 0886260516646093. doi:10.1177/0886260516646093 http://journals.sagepub.com/doi/ abs/10.1177/0886260516646093?journalCode=jiva

PERSONS EXPERIENCING HOMELESSNESS Baker, C. K., Billhardt, K. A., Warren, J., Rollins, C., & Glass, N. E. (2010). Domestic violence, housing instability, and homelessness: A review of housing policies and program practices for meeting the needs of survivors. Aggression and Violent Behavior, 15(6), 430-439. https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=254945

Crawford, D. M., Whitbeck, L. B., & Hoyt, D. R. (2011). Propensity for Violence among Homeless and Runaway Adolescents: An Event History Analysis*. Crime and delinquency, 57(6), 950-968. doi:10.1177/0011128709335100 http://journals.sagepub.com/doi/ abs/10.1177/0011128709335100?journalCode=cadc

Ferguson, K. M. (2008). Exploring Family Environment Characteristics and Multiple Abuse Experiences Among Homeless Youth. Journal of Interpersonal Violence, 24(11), 1875-1891. doi:10.1177/0886260508325490 http://journals.sagepub.com/doi/10.1177/0886260508325490

Heerde, J. A., & Hemphill, S. A. (2015). Sexual Risk Behaviors, Sexual Offenses, and Sexual Victimization Among Homeless Youth. Trauma, Violence, & Abuse, 17(5), 468-489. doi:10.1177/1524838015584371 http://journals.sagepub.com/doi/ abs/10.1177/1524838015584371?journalCode=tvaa

Petering, R. (2016). Sexual Risk, Substance Use, Mental Health, and Trauma Experiences of Gang-Involved Homeless Youth. Journal of Adolescence, 48, 73-81. doi:10.1016/j.adolescence.2016.01.009 https://linkinghub.elsevier.com/retrieve/pii/S0140197116000208

Petering, R., Rhoades, H., Rice, E., & Yoshioka-Maxwell, A. (2015). Bidirectional Intimate Partner Violence and Drug Use Among Homeless Youth. Journal of Interpersonal Violence, 32(14), 2209-2217. doi:10.1177/0886260515593298

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Slesnick, N., Erdem, G., Collins, J., Patton, R., & Buettner, C. (2010). Prevalence of Intimate Partner Violence Reported by Homeless Youth in Columbus, Ohio. Journal of Interpersonal Violence, 25(9), 1579-1593. doi:10.1177/0886260509354590 http://journals.sagepub.com/doi/10.1177/0886260509354590

Sullivan, C. M., Bomsta, H. D., & Hacskaylo, M. A. (2016). Flexible Funding as a Promising Strategy to Prevent Homelessness for Survivors of Intimate Partner Violence. Journal of Interpersonal Violence, 0886260516664318. doi:10.1177/0886260516664318 http://journals.sagepub.com/doi/abs/10.1177/0886260516664318

Tsai, A. C., Weiser, S. D., Dilworth, S. E., Shumway, M., & Riley, E. D. (2015). Violent Victimization, Mental Health, and Service Utilization Outcomes in a Cohort of Homeless and Unstably Housed Women Living With or at Risk of Becoming Infected With HIV. American Journal of Epidemiology, 181(10), 817-826. doi:10.1093/aje/kwu350 https://academic.oup.com/aje/article/181/10/817/158568

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Vijayaraghavan, M., Tochterman, A., Hsu, E., Johnson, K., Marcus, S., & Caton, C. L. M. (2012). Health, Access to Health Care, and Health Care use Among Homeless Women with a History of Intimate Partner Violence. Journal of community health, 37(5), 1032-1039. doi:10.1007/ s10900-011-9527-7 https://link.springer.com/article/10.1007%2Fs10900-011-9527-7

MIGRANT FARM WORKERS Chen, P.-H., Rovi, S., Vega, M., Jacobs, A., & Johnson, M. S. (2005). Screening for domestic violence in a predominantly Hispanic clinical setting. Family Practice, 22(6), 617-623. doi:10.1093/fampra/cmi075 https://academic.oup.com/fampra/article/22/6/617/497968

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Selected Readings on Vulnerable Populations Seasonal Farmworkers in Rural Southeastern North Carolina. Journal of Immigrant and Minority Health, 16(6), 1217-1224. doi:10.1007/ s10903-014-0007-x

5th Annual Communities of Practice Conference B. (2014). Intimate Partner Violence Screening Among Migrant/ Seasonal Farmworker Women and Healthcare: A Policy Brief. Journal of community health, 39(2), 372-377. doi:10.1007/s10900-013-9772-z

https://link.springer.com/article/10.1007%2Fs10903-014-0007-x

https://link.springer.com/article/10.1007%2Fs10900-013-9772-z

Kugel, C., Retzlaff, C., Hopfer, S., Lawson, D. M., Daley, E., Drewes, C., & Freedman, S. (2009). Familias con Voz: Community Survey Results from an Intimate Partner Violence (IPV) Prevention Project with Migrant Workers. Journal of Family Violence, 24(8), 649-660. doi:10.1007/s10896-009-9263-2

MEDICAL EDUCATION

https://link.springer.com/article/10.1007/s10896-009-9263-2

Larson, O. W., Doris, J., & Alvarez, W. F. (1987). Child maltreatment among U.S. east coast migrant farm workers. Child Abuse & Neglect, 11(2), 281-291. doi:http://dx.doi.org/10.1016/0145-2134(87)90068-8 https://www.ncbi.nlm.nih.gov/pubmed/3496144

Lopez, M. J., Mintle, R. A., Smith, S., Garcia, A., Torres, V. N., Keough, A., & Salgado, H. (2015). Risk Factors for Intimate Partner Violence in a Migrant Farmworker Community in Baja California, México. Journal of Immigrant and Minority Health, 17(6), 1819-1825. doi:10.1007/ s10903-014-9988-8 https://link.springer.com/article/10.1007%2Fs10903-014-9988-8

Martin, S. L., Gordon, T. E., & Kupersmidt, J. B. (1995). Survey of exposure to violence among the children of migrant and seasonal farm workers. Public Health Reports, 110(3), 268-276. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1382117/

Moracco, K. E., Hilton, A., Hodges, K. G., & Frasier, P. Y. (2005). Knowledge and Attitudes About Intimate Partner Violence Among Immigrant Latinos in Rural North Carolina. Violence Against Women, 11(3), 337-352. doi:10.1177/1077801204273296 http://journals.sagepub.com/doi/10.1177/1077801204273296

R, R. (1998). Clinical interventions with battered migrant farm worker women. In e. Campbell JC (Ed.), Empowering Survivors of Abuse: Health Care for Battered Women and their Children. (pp. 271-279). Thousand Oaks, CA: Sage.

Rich-Edwards JW, Mason S, Rexrode K, et al. Physical and sexual abuse in childhood as predictors of early onset cardiovascular events in women. Circulation. 2012;126(8):920-927. 11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3649533/

Suglia SF, Sapra KJ, Koenen KC. Violence and Cardiovascular Health: A Systematic Review. American journal of preventive medicine. 2015;48(2):205-212. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4300436/

Duncan AE, Auslander WF, Bucholz KK, Hudson DL, Stein RI, White NH. Relationship Between Abuse and Neglect in Childhood and Diabetes in Adulthood: Differential Effects By Sex, National Longitudinal Study of Adolescent Health. Preventing chronic disease. 2015;12:E70. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4436043/

Khan A, McCormack HC, Bolger EA, et al. Childhood Maltreatment, Depression, and Suicidal Ideation: Critical Importance of Parental and Peer Emotional Abuse during Developmental Sensitive Periods in Males and Females. Frontiers in psychiatry. 2015;6:42. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4378368/

Kohl K, Gross I, Harrison P, Richards M. Numbing and Hyperarousal as Mediators of Exposure to Community Violence and Depression in Urban African-American Youth. Journ Child Adol Trauma. 2015;8(1):33-43. https://link.springer.com/article/10.1007/s40653-015-0038-z

Stringhini S, Batty GD, Bovet P, et al. Association of Lifecourse Socioeconomic Status with Chronic Inflammation and Type 2 Diabetes Risk: The Whitehall II Prospective Cohort Study. PLoS Medicine. 2013;10(7):e1001479.

Short LM, R. R. (2002). Testing an intimate partner violence assessment icon form with battered migrant and seasonal farmworker women. Women Health, 35(2-3), 181-192.

https://doi.org/10.1371/journal.pmed.1001479

Van Hightower, N. R., Gorton, J., & DeMoss, C. L. (2000). Predictive Models of Domestic Violence and Fear of Intimate Partners Among Migrant and Seasonal Farm Worker Women. Journal of Family Violence, 15(2), 137-154. doi:10.1023/A:1007538810858

https://doi.org/10.1016/j.jadohealth.2015.09.021

https://www.ncbi.nlm.nih.gov/pubmed/12201507

https://link.springer.com/article/10.1023/A:1007538810858

Watch, H. R. (2012). Cultivating fear: the vulnerability of immigrant farm workers in the US to sexual violence and sexual harassment. Human Rights Watch Report, . Retrieved from https://www.hrw. org/report/2012/05/15/cultivating-fear/ https://www.hrw.org/report/2012/05/15/cultivating-fear/vulnerabilityimmigrant-farmworkers-us-sexual-violence-and-sexual

Wilson, J. B., Rappleyea, D. L., Hodgson, J. L., Brimhall, A. S., Hall, T. L., & Thompson, A. P. (2016). Healthcare providers’ experiences screening for intimate partner violence among migrant and seasonal farmworking women: A phenomenological study. Health Expectations : An International Journal of Public Participation in Health Care and Health Policy, 19(6), 1277-1289. doi:10.1111/hex.12421 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5139058/

Wilson, J. B., Rappleyea, D. L., Hodgson, J. L., Hall, T. L., & White, M.

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Turner HA, Shattuck A, Finkelhor D, Hamby S. Polyvictimization and Youth Violence Exposure Across Contexts. Journal of Adolescent Health.n2016 Feb;58(2):208-14.

5th Annual Communities of Practice Conference

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2019 CONFERENCE

Selected Readings on Vulnerable Populations by Topics for Communities of Practice INTERPERSONAL VIOLENCE AND SEXUAL VIOLENCE

Centers for Disease Control and Prevention (CDC). Youth Violence. Atlanta, GA: CDC, 2019. Available at:

Alhusen JL, Ray E, Sharps P, et al. Intimate partner violence during pregnancy: maternal and neonatal outcomes. J Womens Health (Larchmt). 2015 Jan; 24(1):100– 6. Epub 2014 Sep 29.

https:// www .cdc .gov/ violenceprevention/ youthviolence / index .html.

Alpert EJ, Tonkin AE, Seeherman AM, et al. Family violence curricula in US medical schools. Am J Prev Med. 1998 May; 14(4):273– 82.

Diaz A, Petersen AC. Institute of medicine report: new directions in child abuse and neglect research. JAMA Pediatr. 2014 Feb; 168(2):101– 2.

Aluko OE, Beck KH, Howard DE. Medical students’ beliefs about screening for intimate partner violence: a qualitative study. Health Promot Pract. 2015 Jul; 16(4):540– 9.

DuRant RH, Altman D, Wolfson M, et al. Exposure to violence and victimization, depression, substance use, and the use of violence by young adolescents. J Pediatr.2000 Nov; 137(5):707– 13.

American Medical Assocation (AMA). Preventing, identifying & treating violence & abuse. Chicago, IL: AMA, 2019. Available at:

Dutton MA, Green BL, Kaltman SI, et al. Intimate Partner violence, PTSD, and adverse health outcomes. J Interpers Violence. 2006 Jul; 21(7):955– 68.

https:// www .ama- assn .org/ delivering- care/ ethics/ preventing- identifyingtreating- violence- abuse.

Blake GET, Watson ED. Unravelling the complex mechanisms of transgenerational epigenetic inheritance. Curr Opin Chem Biol. 2016 Aug; 33:101– 7. Berenson AB, Wiemann CM, McCombs S. Exposure to violence and associated health- risk behaviors among adolescent girls. Arch Pediatr Adolesc Med. 2001 Nov; 155(11):1238– 42. Bohm B, Zollner H, Fegert JM, Liebhardt H. Child sexual abuse in the context of the Roman Catholic Church: a review of literature from 1981– 2013. J Child Sex Abus. 2014; 23(6):635– 56 Broll R, Huey L. “Every time I try to get out, I get pushed back”: the role of violent victimization in women’s experience of multiple episodes of homelessness. J Interpers Violence. 2020 Sep; 35(17– 18):3379– 404. Browne A. Family violence and homelessness: The relevance of trauma histories in the lives of homeless women. Am J Orthopsychiatry. 1993 Jul; 63(3):370– 84. Buranosky R, Hess R, McNeil MA, et al. Once is not enough: effective strategies for medical student education on intimate partner violence. Violence against Women. 2012 Oct; 18(10):1192– 212. Camp T, Motheral L, Robinson K, et al. A multidisciplinary, experiential, educational curriculum in child abuse: the pediatrician’s role in early recognition, documentation, management, and legal advocacy. J Grad Med Educ. 2014 Jun; 6(2):376– 7. Centers for Disease Control and Prevention (CDC). Family violence education in medical school- based residency programs—Virginia, 1995. MMWR Morbidity and Mortality Weekly Report. 1996 Aug 9; 45(31):669– 71. Connor PD, Nouer SS, Mackey SN, et al. Intimate partner violence education for medical students: toward a comprehensive curriculum revision. South Med J. 2012 Apr; 105(4):211– 5.

Elderton A, Berry A, Chan C. A systematic review of posttraumatic growth in survivors of interpersonal violence in adulthood. Trauma, Violence Abuse. 2017 Apr; 18(2):223– 36. Ernst AA, Houry D, Nick TG, et al. Domestic violence awareness and prevalence in a first‐year medical school class. Acad Emerg Med. 1998 Jan; 5(1):64– 8. Ernst AA, Houry D, Weiss SJ, et al. Domestic violence awareness in a medical school class: 2-year follow-up. South Med J. 2000 Aug; 93(8):772– 6. Family violence: an AAFP white paper. The AAFP Commission on Special Issues and Clinical Interests. Am FAM Physician. 1994 Dec; 50(8):1636‐40, 1644– 6. Farrell AD, Bruce SE. Impact of exposure to community violence on violent behavior and emotional distress among urban adolescents. J Clin Child Psychol. 1997 Mar; 26(1):2– 14. Fedina L, Williamson C, Perdue T. Risk factors for domestic child sex trafficking in the United States. J Interpers Violence. 2019 Jul; 34(13):2653– 73. Epub 2016 Jul 27. Flentje A, Livingston NA, Roley J, Sorensen JL. Mental and physical health needs of lesbian, gay, and bisexual clients in substance abuse treatment. J Subst Abuse Treat. 2015 Nov; 58:78– 83. Foshee VA, Benefield TS, Reyes HLM, et al. The peer context and the development of the perpetration of adolescent dating violence. J Youth Adolesc. 2013 Apr; 42(4):471– 86. Epub 2013 Feb 5. Fox JA, DeLateur MJ. Mass shootings in America: Moving beyond Newtown. Homicide Studies. 2014; 18(1):125– 45. Gawad NA, Hestla G, Findley JC. Medical students actively seek gun violence education. Acad Psychiatry. 2018 Dec; 42(6):873– 874. Epub 2018 Jul 9.

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Groger N, Matas E, Gos T, et al. The transgenerational transmission of childhood adversity: behavioral, cellular, and epigenetic correlates. J Neural Transm (Vienna). 2016 Sep; 123(9):1037– 52

Olofsson N. A Life course model of self- reported violence exposure and ill- health with a public health problem perspective. AIMS Public Health. 2014 Jan 27; 1(1):9– 24.

Hamberger LK. Preparing the next generation of physicians: medical school and residency- based intimate partner violence curriculum and evaluation. Trauma Violence Abuse. 2007 Apr; 8(2):214– 25.

Randall T. ACOG renews domestic violence campaign, calls for changes in medical school curricula. JAMA. 1992 Jun 17; 267(23):3131.

Hammick M, Dornan T, Steinert Y. Conducting a best evidence systematic review. Part 1: From idea to data coding. BEME Guide No. 13. Med Teach. 2010 Jan; 32(1):3– 15. Heerde JA, Hemphill SA. Sexual risk behaviors, sexual offenses, and sexual victimization among homeless youth. Trauma Violence Abuse. 2016 Dec; 17(5):468– 89. Hendricks- Matthews M. A survey on violence education: a report of the STFM Violence Education Task Force. Fam Med. 1991 Mar– Apr; 23(3):194– 7. Hertz MF, Everett Jones S, Barrios L, et al. Association between bullying victimization and health risk behaviors among high school students in the United States. J Sch Health. 2015 Dec; 85(12):833– 42. Hill JR. Teaching about family violence: a proposed model curriculum. Teach Learn Med. 2005 spring; 17(2):169– 78. Ivanoff CS, Hottel TL. Comprehensive training in suspected child abuse and neglect for dental students: a hybrid curriculum. J Dent Educ. 2013 Jun; 77(6):695– 705. Jack SPD, Petrosky E, Lyons BH, et al.Surveillance for violent deaths— National Violent Death Reporting System, 27 states, 2015. MMWR Surveill Summ. 2018 Sep 28; 67(11):1– 32. Kingston CP, Penhale B, Bennett G. Is elder abuse on the curriculum? The relative contribution of child abuse, domestic violence and elder abuse in social work, nursing and medicine qualifying curricula. Health & Social Care in the Community. 1996 Nov; 3(6):353– 62. Martin SL, Gordon TE, Kupersmidt JB. Survey of exposure to violence among the children of migrant and seasonal farm workers. Public Health Rep. 1995 May– Jun; 110(3):268– 76. Miller AW, Coonrod DV, Brady MJ, Moffitt MP, Bay RC. Medical student training in domestic violence: A comparison of students entering residency training in 1995 and 2001. Teach Learn Med. 2004 winter; 16(1):3– 6. Miller GE, Chen E, Parker KJ. Psychological stress in childhood and susceptibility to the chronic diseases of aging: moving towards a model of behavioral and biological mechanisms. Psychol Bull. 2011 Nov; 137(6):959– 97. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta- analyses: the PRISMA statement. J Clin Epidemiol. 2009 Oct; 62(10):1006– 12. Nygren P, Nelson HD, Klein J. Screening children for family violence: a review of the evidence for the US Preventive Services Task Force. Ann Fam Med. 2004 Mar– Apr; 2(2):161– 9.

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Resnick HS, Acierno R, Kilpatrick DG. Health impact of interpersonal violence 2: medical and mental health outcomes. Behav Medicine. 1997 summer; 23(2):65– 78. Rickert VI, Wiemann CM, Vaughan RD, et al. Rates and risk factors for sexual violence among an ethnically diverse sample of adolescents. Arch Pediatr Adolesc Med. 2004 Dec; 158(12):1132– 9. Roberts AL, Austin SB, Corliss HL, et al. Pervasive trauma exposure among us sexual orientation minority adults and risk of posttraumatic stress disorder. Am J Public Health. 2010 Dec; 100(12):2433– 41. Rosenberg ML, Fenley MA, eds. Violence in America: a public health approach. New York, NY: Oxford University Press, 1991. Rosenberg ML, ed. Violence as a Public Health Problem: Background Papers for the Surgeon General’s Workshop on Violence and Public Health. Leesburg, VA, 1985. Rosenberg ML, Butchart A, Mercy J, et al. Interpersonal violence. In: Jamison DT, Breman JG, Measham AR, et al eds. Center for Disease Control Priorities in Developing Countries, 2nd ed. New York, NY and Washington DC: Oxford University Press and the World Bank, 2006. Rovi S, Mouton CP. Domestic violence education in family practice residencies. Fam Med. 1999 Jun; 31(6):398– 403. Sarkar NN. The impact of intimate partner violence on women’s reproductive health and pregnancy outcome. J Obstet Gynaecol. 2008 Apr; 28(3):266– 71. Scott CJ, Matricciani RM. Joint Commission on Accrediation of Healthcare Organizations standards to improve care for victims of abuse. Md Med J. 1994 Oct; 43(10): 891– 8. Teresi JA, Burnes D, Skowron EA, et al. State of the science on prevention of elder abuse and lessons learned from child abuse and domestic violence prevention: toward a conceptual framework for research. J Elder Abuse Negl. Aug– Dec 2016; 28(4– 5):263– 300. Thurston WE, Roy A, Clow B, et al. Pathways into and out of homelessness: domestic violence and housing security for immigrant women. Journal of Immigrant & Refugee Studies. 2013; 11(3):278– 98. Tippett EC. The legal implications of the MeToo movement. Getzville, NY: William S Hein & Co, Inc, 2018. Available at:

https:// heinonline.org/ HOL/ Landing Page? mhandle=hein.journals/ mnlr103&div=15&id=&page.

Waalen J, Goodwin MA, Spitz AM, et al. Screening for intimate partner violence by health care providers: barriers and interventions. Am J Prev Med. 2000 Nov; 19(4):230– 7.

5th Annual Communities of Practice Conference

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Waugh IM. Examining the sexual harassment experiences of Mexican immigrant farm working women. Violence against Women. 2010 Mar; 16 (3):237– 61.

D’Onofrio G, Chawarski MC, et al. Emergency department buprenorphine for opioid dependence with continuation in primary care. Outcomes during and after intervention. J Gen Intern Med. 2017 Jun; 32(6):660– 6.

Weatherred JL. Child sexual abuse and the media: a literature review. J Child Sex Abus. 2015; 24(1):16– 34.

Evans EA, Yoo C, Huang D, et al. Effects of access barriers and medication acceptability on buprenorphine- naloxone treatment utilization over 2 years: results from a multisite randomized trial of adults with opioid use disorder. J Subst Abuse Treat. 2019 Nov; 106:19– 28.

Whitton SW, Newcomb ME, Messinger AM, et al. A longitudinal study of IPV victimization among sexual minority youth. J Interpers Violence. 2016 May 3; 34 (5):912– 45. Wong LH, Shumway M, Flentje A, Riley ED. Multiple types of childhood and adult violence among homeless and unstably housed women in San Francisco. Violence Vict. 2016 Dec 1; 31(6):1171– 182. World Health Assembly 49.25: Prevention of violence: a public health priority: Hearing before the Forty- Ninth World Health Assembly (May 1996). World Health Organization (WHO). Violence: a public health priority. Geneva, Switzerland: WHO, 1996.

Evans JL, Tsui JI, Hahn JA, et al. Mortality among young injection drug users in San Francisco: a 10-year follow-up of the UFO study. Am J Epidemiol. 2012 Feb 15; 175(4):302– 8. Epub 2012 Jan 6. Fei JTB, Yee A, Habil MHB, et al. Effectiveness of methadone maintenance therapy and improvement in quality of life following a decade of implementation. J Subst Abuse Treat. 2016 Oct; 69:50– 6. Fullerton CA, Kim M, Thomas CP, et al. Medication- assisted treatment with methadone: assessing the evidence. Psychiatr Serv. 2014 Feb 1; 65(2):146– 57.

World Health Organization (WHO). Report of the Consultation on Child Abuse Prevention. Geneva, Switzerland, 1999. Available at:

Gunderson EW, Coffin PO, Chang N, et al. The interface between substance abuse, Opioid use training in medical school and chronic pain management in primary care: a curriculum for medical residents. Subst Abus. Jul– Sep 2009; 30(3):253– 60.

OPIOID ABUSE

Jarvis BP, Holtyn AF, Subramaniam S, et al. Extended- release injectable naltrexone for opioid use disorder: a systematic review. Addiction. 2018 Jul; 113(7):1188– 209.

https:// apps.who.int/ iris/ handle / 10665/ 65900.

Abdu- Quader AS, Feelmyer J, Modi S, et al. Effectiveness of structural level needle/ syringe programs to reduce HCV and hiv infection among people who inject drugs: a systematic review. AIDS Behav. 2013 Nov; 17 (9):2878– 92. Brown AT, Kolade VO, Staton LJ, et al. Knowledge of addiction medicine among internal medicine residents and medical students. Tenn Med. 2013 Mar: 106(3):31– 3. Carrieri P, Vilotitch A, Nordmann S, et al. Decrease in self- reported offences and incarceration rates during methadone treatment: a comparison between patients switching from buprenorphine to methadone and maintenance treatment incident users. Int J Drug Policy. 2017 Jan; 39:86– 91. Centers for Disease Control and Prevention (CDC). Drug Overdose Deaths. Atlanta, GA: CDC, 2020. Available at: https:// www .cdc .gov/ drugoverdose/ data/ statedeaths .html.

Center for Behavioral Health Statistics and Quality. Results from the 2017 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018. Available at: https:// www .samhsa .gov/ data/ sites/ default/ files/ cbhsq- reports/ NSDUHDetailedTabs2017/ NSDUH DetailedTabs2017 .pdf.

DiClemente CC, Corno CM, Graydon MM, et al. Motivation interviewing, enhancement, and brief interventions over the last decade: a review of re reviews of efficacy and effectiveness. Psychol Addict Behav. 2017 Dec; 31(8):862– 87.

Kim H, Heverling H, Corderio M, et al. Internet training resulted in improved trainee performance in a simulated opioid- poisoned patient as measured by checklist. J Med Toxicol. 2016 Sep; 12(3):289– 94. Epub 2016 Apr 1. Kunins HV, Sohler NL, Giovanniello A, et al. A buprenorphine education and training program for primary care residents: implementation and evaluation. Subst Abus. 2013; 34(3):242– 7. Ling W, Mooney L, Torrington M. Buprenorphine for opioid addiction. Pain Manag. 2012 Jul;2(4):345– 50. Makarenko I, Pykalo I, Springer SA, et al. Treating opioid dependence with extended release naltrexone (XR-NTX) in Ukraine. Feasibility and threemonth outcomes. J Subst Abuse Treat. 2019 Sep; 104:34– 41. Epub 2019 May 10. Mark TL, Parish WJ, Zarkin GA. Association of formulary prior authorization policies with buprenorphine- naloxone prescriptions and hospital and emergency department use among medicare beneficiaries. JAMA Netw Open. 2020 Apr 1; 3(4):e203132. Mauger S, Fraser R, Gill K. Utilizing buprenorphine- naloxone to treat illicit and prescription- opioid dependence. Neuropsychiatr Dis Treat. 2014 Apr 7; 10:587– 98. Maxwell S, Bigg D, Stanczykiewicz K, et al. Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths. J Addict Dis. 2006; 25(3):89– 96.

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Metzger DS, Donnell D, Celentano DD, et al. Expanding substance use treatment options for HIV prevention with buprenorphine- naloxone: HIV Prevention Trials Network 058. J Acquir Immune Defic Syndr. 2015 Apr 15; 68(5):554– 61.

Wakeman SE, Pham- Kanter G, Baggett MV. Medicine resident preparedness to diagnose and treat substance use disorders: impact of an enhanced curriculum. Subst. Abus. 2015; 36(4):427– 33. Epub 2014 Sep 25.

Monterio K, Dumenco L, Collins S, et al. An interprofessional education workshop to develop health professional student opioid misuse knowledge, attitudes, and skills. J Am Pharm Assoc (2003). 2017 Mar– Apr; 57(2S):S113– 7.

Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013 Jan 30; 346:f174.

Moore BA, Fiellin DA, Cutter CJ, et al. Cognitive behavioral therapy improves treatment outcomes for prescription opioid users in primarycare based buprenorphine treatment. J Subst Abuse Treat. 2016 Dec; 71:54– 7.

Weinstein ZM, Kim HW, Cheng DM, et al. Long- term retention in Office Based Opioid Treatment with buprenorphine. J Subst Abuse Treat. 2017 Mar; 74:65– 70.

Morgan JR, Schackman BR, Weinstein ZM, et al. Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort. Drug Alcohol Depend. 2019 Jul 1; 200:34–42 Nolan S, Lima VD, Fairbairn N, et al. The impact of methadone maintenance therapy on hepatitis C incidence among illicit drug users. 2014 Dec; 109(12):2053– 9. Epub2014 Aug 14. https:// doi .org/ 10.1111/ add.12682

Noroozi M, Armoon B, Ghisynd H, et al. Prevelance and risk factors for injection site skin infections among people who inject drugs (PID) in Tehran. J Cosmet Dermatol. 2019 Feb; 18(1):258– 62. Patel RM, Foote C, Duwye J, et al. Reduction of injection- related risk behaviors after emergency implementation of a syringe services program during an HIV outbreak.J Acquir Immune Defic Syndr. 2018 Apr 1; 77(4):373– 82. Reed M, Wagner KD, Tran NK, et al. Prevalence and correlates of carrying naloxone among a community- based sample of opioid- using people who inject drugs. Int J Drug Policy. 2019 Nov; 73:32– 5. Rettig RA, Yarmolinsky A, eds. Institute of Medicine (US) Committee of Federal Regulation of Methadone Treatment. Washington, DC: National Academies Press, 1995. Roth A, Aumajer BL, Felsher MA, et al. An exploration of factors impacting preexposure prophylaxis eligibility and access among syringe exchange users. Sex Transm. Dis. 2018 Apr; 45(4):217– 21. Ruff AL, Alford DP, Butler R, et al. Training internal medicine residents to manage chronic pain and prescription opioid misuse. Subst Abus. Apr– Jun 2017; 3 (2):200– 4. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta- analysis of cohort studies. BMJ. 2017 Apr 26; 357:j1550. Taylor JL, Rapoport AB, Rowley CF, et al. An opioid overdose curriculum for medical residents: Impact on naloxone prescribing, knowledge, and attitudes. Subst Abus. 2018; 39(3):371– 376. Epub 2018 May 15.

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Wiegand TJ. The new kid on the block—incorporating buprenorphine into a medical toxicology practice. J Med Toxicol. 2016 Mar; 12(1):64– 70. Woody G, Bruce D, Korthuis PT, et al. HIV risk reduction with buprenorphine naloxone or methadone: findings from a randomized trial. J Acquir Immune Defic Syndr. 2014 Jul 1; 66(3):288– 93.

5th Annual Communities of Practice Conference

Selected Readings on Vulnerable Populations

2020 CONFERENCE

Selected Readings on Vulnerable Populations by Topics for Communities of Practice AFFIRMING CARE Arora, M., Walker, K., Duvivier, R. J., & Wynne, K. (2018). The effect of an educational session on attitudes toward delivery of transgender healthcare by medical students and general practitioners in the Hunter region. Clinical Endocrinology, Conference, Endocrine Society of Australia Annual Scientific Meeting 2017. Australia. 2089 (Supplement 2011) (pp 2042-2043). Bakhai N, Ramos J, Gorfinkle N, et al. Introductory learning of inclusive sexual history taking: an e-lecture, standardized patient case, and facilitated debrief. MedEdPORTAL. 2016; 12:10520. Bakhai N, Shields R, Barone M, Sanders R, Fields E. An active learning module teaching advanced communication skills to care for sexual minority youth in clinical medical education. MedEdPORTAL. 2016; 12:10449. Braun HM, Garcia-Grossman IR, Quiñones-Rivera A, Deutsch MB. Outcome and Impact Evaluation of a Transgender Health Course for Health Profession Students. LGBT Health. 2017 Feb;4(1):55-61. Buhalog, B., Peebles, J. K., Mansh, M., Kim, E. A., Knott, P. D., Hoffman, W., Arron, S. T. (2019). Trainee Exposure and Education for Minimally Invasive Gender-Affirming Procedures. Dermatologic Clinics. doi:10.1016/j. det.2019.10.009 Calzo JP, Melchiono M, Richmond TK, Leibowitz SF, Argenal RL, Goncalves A, Pitts S, Gooding HC, Burke P. Lesbian, gay, bisexual, and transgender adolescent health: an Interprofessional case discussion. MedEdPORTAL. 2017; 13:10615. Cherabie, J., Nilsen, K., & Houssayni, S. (2018). Transgender Health Medical Education Intervention and its Effects on Beliefs, Attitudes, Comfort, and Knowledge. Kans J Med, 11(4), 106-109. Click IA, Mann AK, Buda M, Rahimi-Saber A, Schultz A, Shelton KM, Johnson L. Transgender health education for medical students. Clin Teach. 2020 Apr; 17(2):190-194. Eriksson, S. E., & Safer, J. D. (2016). Evidence-Based Curricular Content Improves Student Knowledge and Changes Attitudes Towards Transgender Medicine. Endocr Pract, 22(7), 837-841. doi:10.4158/EP151141 Grosz, A. M., Gutierrez, D., Lui, A. A., Chang, J. J.,Cole-Kelly, K., & Ng, H. (2017). A Student-Led Introduction to Lesbian, Gay, Bisexual, and Transgender Health for First-Year Medical Students. Fam Med, 49(1), 52-56. Kelley, L., Chou, C. L., Dibble, S. L., & Robertson, P. A. (2008). A critical intervention in lesbian, gay, bisexual, and transgender health: knowledge and attitude outcomes among second-year medical students. Teach Learn Med, 20(3), 248-253. doi: 10.1080/10401330802199567

Marshall A, Pickle S, Lawlis S.Transgender medicine curriculum: integration into an organ system–based preclinical program. MedEdPORTAL. 2017; 13:10536. Neff A, Kingery S. Complete androgen insensitivity syndrome: a problembased learning case. MedEdPORTAL. 2016; 12:10522. Park JA, Safer JD (2018) Clinical exposure to transgender medicine improves students’ preparedness above levels seen with didactic teaching alone: a key addition to the Boston University Model for teaching transgender healthcare, Transgender Health 3:1, 10–16, DOI: 10.1089/trgh.2017.0047. Safer, J. D., & Pearce, E. N. (2013). A simple curriculum content change increased student comfort with transgender medicine. Endocr Pract, 19(4), 633-637. Sawning S, Steinbock S, Croley R, Combs R, Shaw A, Ganzel T. A first step in addressing medical education Curriculum gaps in lesbian-, gay-, bisexual-, and transgender-related content: The University of Louisville Lesbian, Gay, Bisexual, and Transgender Health Certificate Program. Educ Health (Abingdon). 2017 May-Aug;30(2):108-114. Thomas, D. D., & Safer, J. D. (2015). A Simple Intervention Raised ResidentPhysician Willingness to Assist Transgender Patients Seeking Hormone Therapy. Endocr Pract, 21(10), 1134-1142. doi:10.4158/EP15777 Thompson, H., Coleman, J. A., Iyengar, R. M., Phillips, S., Kent, P. M., & Sheth, N. (2019). Evaluation of a gender-affirming healthcare curriculum for second-year medical students. Postgrad Med J. doi:10.1136/ postgradmedj-2019-136683 Ufomata E, Eckstrand KL, Hasley P, Jeong K, Rubio D, Spagnoletti C. Comprehensive Internal Medicine Residency Curriculum on Primary Care of Patients Who Identify as LGBT. LGBT Health. 2018 Aug/Sep;5(6):375-380. Underman, K., Giffort, D., Hyderi, A., & Hirshfield, L. E. (2016). Transgender Health: A Standardized Patient Case for Advanced Clerkship Students. MedEdPORTAL, 12, 10518. doi:10.15766/mep_2374-8265.10518

IMMUNIZATION DISPARITIES Afonso N, Kavanagh M, Swanberg S.Improvement in attitudes toward influenza vaccination in medical students following an integrated curricular intervention,Vaccine 2014; 32 (4): 502-506. Belkowitz J, Peter G. Immunization Basics and Case-Based Discussion. MedEd Portal December 2014; https://doi.org/10.15766/mep_2374-8265.9983

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Selected Readings on Vulnerable Populations Campbell JR, Szilagyi PG, Rodewald LE, Winter NL, Humiston SG, Roghmann KJ. Intent to immunize among pediatric and family medicine residents. Arch Pediatr Adolesc Med. 1994 Sep;148(9):926-9. Coleman A, Lehman D. A flipped classroom and case-based curriculum to prepare medical students for vaccine-related conversations with parents. MedEdPORTAL. 2017; 13:10582. Ghandora H, Halperin DM, Isenor JE, Taylor BA, Fullsack P, Di Castri AM, Halperin SA. Knowledge, attitudes, behaviours, and beliefs of healthcare provider students regarding mandatory influenza vaccination. Hum Vaccin Immunother. 2019; 15(3):700-709. Jackman S, Nair D. Immunization TBL exercise. MedEd Portal September 2012 https://doi.org/10.15766/mep_2374-8265.9230 Koski K, Lehto JT, Hakkarainen K. Simulated Encounters with Vaccine-Hesitant Parents: Arts-Based Video Scenario and a Writing Exercise. J Med Educ Curric Dev. 2018 Aug 2; 5:2382120518790257. Laitman BM, Ronner L, Oliver K, Genden E. US Medical Trainees' Knowledge of Human Papilloma Virus and Head and Neck Cancer. Otolaryngol Head Neck Surg. 2020 Jan; 162(1):56-59. Latella AE, McAuley RJ, Rabinowitz M. Beliefs about Vaccinations: Comparing a Sample from a Medical School to That from the General Population. Int. J. Environ. Res. Public Health 2018, 15, 620; doi: 10.3390/ijerph15040620 Molloy MM, Jones A, Johnson M, Stewart R, McGuire M. Pediatrics Training Modules for Preclinical Medical Students. MedEd Portal January 2015. https://doi.org/10.15766/mep_2374-8265.9996

Onello E, Friedrichsen S, Krafts K, Simmons G Jr, Diebel K. First year allopathic medical student attitudes about vaccination and vaccine hesitancy. Vaccine. 2020 Jan 22; 38(4):808-814. Pelly LP, Pierrynowski MacDougall DM, Halperin BA. et al. THE VAXED PROJECT: An Assessment of Immunization Education in Canadian Health Professional Programs. BMC Med Educ 10, 86 (2010). https://doi.org/10.1186/1472-6920-10-86

Schnaith AM, Evans EM, Vogt C, Tinsay AM, Schmidt TE, Tessier KM, Erickson BK. An innovative medical school curriculum to address human papillomavirus vaccine hesitancy. Vaccine. 2018 Jun 18;36(26):3830-3835. Stalvey C, Rathe R. Practice-Based Learning and Improvement: Improving Residents' Performance in Providing Preventive Care through a Web-Based Chart Audit System. MedEd Portal January 2015. https://doi.org/10.15766/mep_2374-8265.9996

Tsai M, Pessel C, Cason M, Fitzgerald E, Shah A, So-Young O, Lee S, Kraja V, Vieira D, Garcia J, Maxwell E, Phan S. Cervical Cancer Prevention and Screening. MedEd Portal April 2011. https://doi.org/10.15766/mep_2374-8265.8174

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5th Annual Communities of Practice Conference Whitaker JA, Poland CM, Beckman TJ, Bundrick JB, Chaudhry R, Grill DE, Halvorsen AJ, Huber JM, Kasten MJ, Mauck KF, Mehta RA, Olson T, Thomas KG, Thomas MR, Virk A, Wingo MT, Poland GA. Immunization education for internal medicine residents: A cluster-randomized controlled trial. Vaccine. 2018 Mar 27; 36(14):1823-1829. Wiley R, Shelal Z, Bernard C, Urbauer D, Toy E, Ramondetta L. Human papillomavirus: from basic science to clinical management for preclinical medical students. MedEdPORTAL. 2018; 14: 10787. Wiley R, Shelal Z, Urbauer D, Bernard R, Ramondetta L. Relationship Between Intent to Vaccinate and the Education and Knowledge of Human Papillomavirus Among Medical School Faculty and Students in Texas. Tex Med. 2019; 115(1); e1. Wilson MW, Brown BJ, Miles MC. A multicomponent intervention to improve pneumococcal vaccination knowledge among internal medicine residents. MedEdPORTAL. 2016; 12:10414. Zimmerman RK, Barker WH, Strikas RA, Ahwesh ER, Mieczkowski TA, Janosky JE, Kanter SL. Developing curricula to promote preventive medicine skills. The Teaching Immunization for Medical Education (TIME) Project. TIME Development Committee. JAMA. 1997 Sep 3; 278(9):705-11.

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2021 CONFERENCE

Selected Readings on Vulnerable Populations by Topics for Communities of Practice MENTAL HEALTH Brown, Taylor; Berman, Sarah; McDaniel, Katherine; Radford, Caitlin; Mehta, Pooja; Potter, Jennifer; Hirsh, David A. Trauma-informed medical education (TIME): Advancing curricular content and educational context. Academic Medicine 2021 ;(): Brondani, M.; Harjani, M.; Siarkowski, M.; Adeniyi, A.; Butler, K.; Dakelth, S.; Maynard, R.; Ross, K.; O'Dwyer, C.; Donnelly, L. Community as the teacher on issues of social responsibility, substance use, and queer health in dental education. PLoS One 2020; 15(8):e0237327. Calzo, J. P.; Melchiono, M.; Richmond, T. K.; Leibowitz, S. F.; Argenal, R. L.; Goncalves, A.; Pitts, S.; Gooding, H. C.; Burke, P. Lesbian, Gay, Bisexual, and Transgender Adolescent Health: An Interprofessional Case Discussion. MedEdPORTAL Aug 9 2017; 13():10615. 2017 Aug 9 Cordingley, L; Peters, S; Hart, J; Rock, J; Hodges, L; McKendree, J; Bundy, C. What psychology do medical students need to know? An evidencebased approach to curriculum development. Health and Social Care Education 2013;2(2):38-47. Doyle, M. A.; Caplan, J. P.; Marcil, W. A student-run psychiatry clinic and its use for a medical-student training experience. Acad Psychiatry May 1 2012; 36(3):237-9. Edison, M. A.; Browne, B.; Fehler, J. Implementation of a medical education programme for addictions MDT members to improve knowledge and confidence in managing substance users with complex comorbidities. BMJ Open Qual Dec 2020; 9 (4): Fadus, M. Mental Health Disparities and Medical Student Education: Teaching in Psychiatry for LGBTQ Care, Communication, and Advocacy. Acad Psychiatry Jun 2019; 43(3):306-310. Fadus, M. C.; Peterson, N. K.; Jilich, C. L.; Kantor, E. M.; Beckert, D. R.; Reed, J. M.; Valadez, E. A.; Brendle, T. A. Improving Communication with LGBTQ Patients: A Pilot Curriculum During the Psychiatry Clerkship. Acad Psychiatry Apr 2020; 44(2):218-222. Freilich, Laura; Lyles, Judith S; Sharma, Mukta; Kavuturu, Shilpa; LairdFick, Heather S; Grayson-Sneed, Katelyn; Smith, Robert C. A Curriculum for Training Medical Faculty to Teach Mental Health Care—and Their Responses to the Learning JCOM 2020; 27(4): 2020 Gay, T. L.; Himle, J. A.; Riba, M. B. Enhanced ambulatory experience for the clerkship: curriculum innovation at the University of Michigan. Acad Psychiatry Summer 2002; 26(2):90-5.

Kauth, M. R.; Shipherd, J. C.; Lindsay, J. A.; Kirsh, S.; Knapp, H.; Matza, L. Teleconsultation and Training of VHA Providers on Transgender Care: Implementation of a Multisite Hub System. Telemed J E Health Dec 2015; 21(12):1012-8. Kelley, L.; Chou, C. L.; Dibble, S. L.; Robertson, P. A. A critical intervention in lesbian, gay, bisexual, and transgender health: knowledge and attitude outcomes among second-year medical students. Teach Learn Med JulSep 2008; 20(3):248-53. McCave, E. L.; Aptaker, D.; Hartmann, K. D.; Zucconi, R. Promoting Affirmative Transgender Health Care Practice Within Hospitals: An IPE Standardized Patient Simulation for Graduate Health Care Learners. MedEdPORTAL 2019; 15:10861. Mishan, L. I.; Dragatsi, D. Student-Run Clinics: A Novel Approach to Integrated Care, Teaching and Recruitment. Community Ment Health J May 2017; 53(4):460-463. Monteiro, K.; Dumenco, L.; Collins, S.; Bratberg, J.; MacDonnell, C.; Jacobson, A.; Dollase, R.; George, P. Substance Use Disorder Training Workshop for Future Interprofessional Health Care Providers MedEdPORTAL May 5 2017;13:10576. Ravindranath, D.; Gay, T. L.; Riba, M. B. Trainees as teachers in team-based learning. Acad Psychiatry Jul-Aug 2010; 34(4):294-7. Shipherd, J. C.; Kauth, M. R.; Firek, A. F.; Garcia, R.; Mejia, S.; Laski, S.; Walden, B.; Perez-Padilla, S.; Lindsay, J. A.; Brown, G.; Roybal, L.; Keo-Meier, C. L.; Knapp, H.; Johnson, L.; Reese, R. L.; Byne, W. Interdisciplinary Transgender Veteran Care: Development of a Core Curriculum for VHA Providers. Transgend Health 2016; 1(1):54-62. Sin, D.; Chew, T.; Chia, T. K.; Ser, J. S.; Sayampanathan, A.; Koh, G. Evaluation of Constructing Care Collaboration - nurturing empathy and peer-topeer learning in medical students who participate in voluntary structured service-learning programmes for migrant workers. BMC Med Educ Aug 8 2019; 19(1):304. Song, A. Y.; Poythress, E. L.; Bocchini, C. E.; Kass, J. S. Reorienting Orientation: Introducing the Social Determinants of Health to First-Year Medical Students. MedEdPORTAL Sep 18 2018; 14():10752. Stovall, J.; Fleisch, S. B.; McQuistion, H. L.; Hackman, A.; Harris, T. Ethics and the Treatment of the Mentally Ill, Homeless Person: a Perspective on Psychiatry Resident Training. Acad Psychiatry Aug 2016; 40(4):612-6.

Ivanov, I. Common problems in psychotherapy training for psychiatry residents. J Psychiatr Pract May 2007; 13(3):184-9.

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Selected Readings on Vulnerable Populations TELEHEALTH Abraham HN, Opara IN, Dwaihy RL, Acuff C, Brauer B, Nabaty R, Levine DL. Engaging Third-Year Medical Students on Their Internal Medicine Clerkship in Telehealth During COVID-19. Cureus. 2020 Jun 24;12 (6):e8791 Alicata D, Schroepfer A, Unten T, Agoha R, Helm S, Fukuda M, Ulrich D, Michels S. Telemental Health Training, Team Building, and Workforce Development in Cultural Context: The Hawaii Experience. J Child Adolesc Psychopharmacol. 2016 Apr;26(3):260-5. Bautista CA, Huang I, Stebbins M, Floren LC, Wamsley M, Youmans SL, Hsia SL. Development of an interprofessional rotation for pharmacy and medical students to perform telehealth outreach to vulnerable patients in the COVID-19 pandemic. J Interprof Care. 2020 Sep-Oct;34(5):694-697. Boyers LN, Schultz A, Baceviciene R, Blanley S, Marvi N, Dellavalle RP, Dunnick CA. Teledermatology as an Educational Tool for Teaching Dermatology to Residents and Medical Students. Telemedicine and e-Health 2015; 21(4): 312314. Chao TN, Frost AS, Brody RM, Byrnes YM, Cannady SB, Luu NN, Rajasekaran K, Shanti RM, Silberthau KR, Triantafillou V, Newman JG. Creation of an Interactive Virtual Surgical Rotation for Undergraduate Medical Education during the COVID-19 Pandemic. J Surg Educ. 2021 Jan-Feb;78(1):346-350. Hindman DJ, Kochis SR, Apfel A, Prudent J, Kumra T, Golden WC, Jung J, Pahwa AK. Improving Medical Students' OSCE Performance in Telehealth: The Effects of a Telephone Medicine Curriculum. Acad Med. 2020 Dec; 95 (12):1908-1912. Jonas CE, Durning SJ, Zebrowski C, Cimino F. An Interdisciplinary, MultiInstitution Telehealth Course for Third-Year Medical Students. Acad Med. 2019 Jun; 94 (6):833-837. Kirkland B, DuBose-Morris R, Duckett A. Telehealth for the internal medicine resident: A 3-year longitudinal curriculum. Journal of Telemedicine and Telecare 2019; 1-7. https://doi.org/10.1177/1357633X19896683

Papanagnou D, Stone D, Chandra S, Watts P, Chang AM, Hollander JE. Integrating Telehealth Emergency Department Follow-up Visits into Residency Training. Cureus. 2018 Apr 5; 10(4):e2433.

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National Center for Medical Education Development and Research UPDATE ON ACTIVITIES

The National Center for Medical Education Development and Research will continue to work closely with HRSA and the Program Officer under the Cooperative Agreement for the Center. The cooperative relationship under Irene Sandvold, PhD, continues to provide oversight for the Center to examine research assumptions, hypotheses, and to develop research studies based on topics jointly selected from the grant. The project staff members will continue to meet weekly under the leadership of Dr. Paul Juarez to discuss the operations of the center and to update the team on current systematic reviews of the literature and interventions that identify gaps in primary care training in addressing the needs of vulnerable populations and to inform primary care training programs and centers how to incorporate research findings into training and clinical care. The team continues to focus on innovative studies that provide information and strategies on access, patient outcomes, quality improvement, efficacy and cost in the provision of health care services to LGBTQ, persons experiencing homelessness, and migrant farm workers. Over the next four months we will: 1) complete the systematic reviews, complete the IRBs for the research projects with the Migrant Clinician Network and Fenway Institute focusing on Affirming Care for LGBTQ and Immunizations for Migrant Farmer Workers. We completed the write up on the survey implementation to the four (4) black medical schools on how they are integrating information about LGBTQ, persons experiencing homeless, and migrant farmer workers into the medical education curriculum; 2) refine the publications on survey results from the national survey sent to 144 medical schools to gain information about their courses or topics in medical education and primary care curriculum focusing on LGBTQ, persons experiencing homelessness, and migrant farmer workers; 3)continue to plan the annual meeting for the Communities of Practice for feedback on evidence-based information that will enhance access, quality, and reduce cost of health care to vulnerable populations such as the one under study; and 4) continue to disseminate findings from existing studies through the website: www.ncmedr.org; national conferences and webinars, and the CoP TV that has now added a cable show. We also plan to continue to participate in collaborative work with the other grantees through shared dissemination mechanisms, e.g. presentations at national meetings, collaboration in research studies, and conferences. The Center will continue to hold quarterly research seminars, symposia, and workshops for the project, which will be crosscutting, bringing together transdisciplinary researchers, including clinical, social-behavioral, translational, health services, environmental health disparities, primary care researchers, community partners, primary care providers, trainees, and students to discuss implications of research findings for clinical practice and preventive care. The research investigators will continue to perform preliminary, intermediate, and final data analysis for each of the two selected projects in Year 4 including reviewing quantitative, qualitative, and multi-level analysis along with the statistician and the Center Director. The team will continue to publish its findings and to present them at national conferences such as the Xavier Health Disparities Conference in New Orleans. They will continue to prepare abstracts and presentations for conferences and grand rounds in the department of Family and Community Medicine. However, the faculty in the Center will balance the development of posters and abstracts with increasing more time in developing more manuscripts. For the next 4 months and into Year 5, we will continue to finalize Year 4 research studies outcomes and categorize findings in the following ways: 1) interventions will be rated as either effective, promising, or no effects. Effective interventions will be assessed to have strong evidence to indicate they achieved their intended outcomes when implemented with fidelity.

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These interventions have at least one evaluation study that is rigorous, well designed and finds significant,positive effects on health-related outcomes. Promising interventions will have some evidence to indicate they achieve their intended outcomes. These interventions have at least one well designed evaluation, but it is slightly less rigorous and/or there may be limitations in the design. Interventions that have been determined to have No Effect will have evaluations that are rigorous and well-designed but found no significant effects on health-related outcomes. Interventions that have no effect and that have been determined to “not address” scoring instrument criteria will not be included in the Matrix of Interventions. Over the next four (4) months, the Center Director will continue to meet with the Curriculum Committee to discuss the findings and outcomes of our studies and the implications for medical education. We will continue to build the brand of the Center with weekly and biweekly meetings held with the staff, the consultants in the Center, national networks, thought leaders, and content experts. Plans for Upcoming Year: In Year 5, the plans are to: 1) select and implement two (2) research projects out of four (4) submitted projects in the initiate grant application. These studies were designed to evaluate primary care training in the implementation model for addressing the needs of vulnerable populations submitted; 2) continue weekly meetings with the staff; 3) maintain and update website; 4) develop and hold two Communities of Practice (CoP) meetings to assess the needs of LGBTQ, migrant workers, and homeless persons, and translate research findings into primary care training and clinical practice guidelines from Years 1, 2, and 3 from the systematic reviews; and 5) disseminate findings and results on the website through social media, presentations at national conferences, and submission of abstracts and manuscripts for publications. We will select and examine studies that reflect barriers to care and access to treatment for health-related problems for these vulnerable populations. The project will continue to use scientific strategies such as:1) meta-analysis; 2) secondary qualitative and quantitative studies; a n d 3) comparative analysis of usual care versus care to determine the model through literature reviews and surveys. An exhaustive search of the literature, (from 2005 until present, using Scopus, PubMed, EBSCOhost, Google Scholar and PsycINFO) continues to be conducted. Other databases that are searched include CINAHL, ERIC, and Web of Science. Following completion of all literature searches, the PRISMA flow diagram will be used to document search results. In Year 4, the CoP will examine system-level models of care that can be translated into pedagogical content for primary care training for LGBTQ, homeless persons, and migrant farm workers. The CoP will build on and incorporate the various experiences and solutions proposed by multiple partners to build a knowledge base representing best practices. In addition, the CoP will provide broader public health benefits, including consistent communication and reporting, improved analytic capability, promotion of standards, support and promotion of key national initiatives, advancement of domain-specific capabilities, linking of geographically dispersed practitioners, and increased efficiency. The Center Director of the Dissemination and the Communities of Practice (CoP) cores will host t h e fourth (4th) meeting for the members of the Communities of Practice. This meeting will focus examining our current work and provide feedback on curricula, research, and effective dissemination practices that will be helpful to community physicians. Emphasis will be on identifying ways to integrate curricula findings, recommendations, and strategies into primary care to improve health outcomes for vulnerable populations and to expand the primary care workforce.

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The Center continues to meet on a weekly basis and will use telephone conferencing with the HRSA Staff and consultants who advise and provide expertise in the research, dissemination, and content subject matter areas for addressing systemic issues affecting LGBTQ, persons experiencing homelessness, and migrant farmer workers. The project will a l s o coordinate the planning and implementation of an assessment of primary care training programs to address current prevention and care practices associated with the above listed populations. During the remainder of Year 4 and the first four months of Year 5, the Dissemination Core (DC) will continue to identify transdisciplinary and multi-sector academic and community partners, and opportunities to assist with translating research findings into culturally appropriate training and messaging. We will integrate these messages into primary care training pedagogical learning modalities and content information to enhance interest in clinical transformation in the medical education community. To assist in tone and language, the NCMEDR have initiated three memoranda of understandings (MOUs). One of the MOUs is with the Migrant Clinicians’ Network. The Migrant Clinicians’ Network is an organization that provide health care to migrant farmer workers. The picture reflecting migrant farmer workers taken by the Migrant Clinicians’ Network. In Year 5, the DC will continue to use blogging, twitter, and other social media platforms to promote our research. At each CoP conference, the CoP members will review and make recommendations on the best dissemination methods. The DC, in conjunction with the Center and HRSA, has established and maintained a communications platform that supports collaborative research, education, communications, and community outreach activities among academic and multi-sector community partners who are committed to providing comprehensive and cost-effective health care to vulnerable populations. The dissemination platform includes: 1) a comprehensive directory/list-serve of community organizations in each state in the region by population, type of services offered, and the availability of culturally appropriate services; 2) a website; 3) a quarterly electronic newsletter; 4) regular videoconferences with targeted audiences; and 5) a full array of supportive resources (e.g., voice, chat, e-mail, IM, CRM tools, web collaboration), which will be incorporated as appropriate. These tools together can be used to provide the best possible communication experience for the Center, HRSA, and its academic/community and patient populations. Core elements will be used to assess the effectiveness of interventions and uptake by primary care training programs in addressing the needs of LGBTQ, migrant farm workers, and persons experiencing homelessness. We will continue to build our communities of practice by including national networks. We continue to expand our CoP by stakeholders who are may be experiencing vulnerability. We will also continue to focus on homelessness as the definition is shifting as noted in this recent article reflecting persons experiencing homelessness in Los Angeles.

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Dissemination activities will continue to target four distinct groups: 1) academics (e.g. publications, presentations); 2) academic primary care educators and providers, leaders of health insurance plans, and public health practitioners (evidence-based findings); 3) public officials and policy analysts (research findings on the effects of public policy on workforce development, diversity, health outcomes, quality of care, access, and continuous quality improvement around health disparities); and 4) the lay community (public health messages). The DC will continue to work with the research and the CoP cores to identify the types of organizations and institutions that will assist in the dissemination of systems research findings, information, and evidencebased interventions. The DC will translate the findings and results of the National Center into training, practice, and policy with a focus on improving primary care training curriculum, health access, and clinical care; crafting appropriate messages to reach different segments of the target population; improving quality of care for population health; and reducing health care costs for services provided to vulnerable populations. Working together with the DC, the CoP will continue to foster interdisciplinary, transdisciplinary, and inter-professional approaches to curriculum design and development, as well as PCMH clinical practice. As a unit, it will continue to provide an overview of opportunities for medical education to incorporate peer learning and peer coaching around the implementation of an evidencebest practice in training and promote best practices in other academic and clinical-based organizations. Major tasks of the CoP will continue to include: 1) feedback; 2) knowledge creation and sharing; 3) identification of best medical education and clinical practices; 4) innovation in primary care curricula; and 5) dissemination. Pictured centered is Thomas A. Arcury, PhD, Consultant, leading the Migrant Farm Workers’ Research Group meeting for CoP 2019. Milestones/Progress by Objectives Objective 1: Establish and sustain an academic unit in the Department of Family and Community Medicine from Years 1-5 through a cooperative agreement with HRSA 1. The National Center for Medical Education Development and Research is fully operational with staff, scheduled regular meetings, website, and regularly structured dissemination and community of practice activities. 2. In Year 4, there has been 35 weekly meetings with the staff of the Center. 3. The Center collaborates with the other five (5) national centers and spearheads the Journal Supplement. 4. To date, the Center has a website with 346,000 visits. 5. The dissemination plan for the Center has been completed and is being implemented. 6. It has a national network of content speakers and thought leaders including Drs. Bev & Etienne Wenger, developers of the concept and theories for CoP and national and international scholars. 7. The Center has four (4) MOUs in place to achieve its work with vulnerable populations: LGBTQ, persons experiencing homelessness, and migrant farm workers. They

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are Fenway Institute, Migrant Clinical Network, The University of Kentucky, departments of family medicine and pediatrics, National HealthCare for the Homeless Council. 8. The Center continues to collaborate with eighteen (18) national partners including Fenway Institute, Migrant Clinicians Network, the National Healthcare for the Homeless Council, and the Single Room Occupancy (SRO) Los Angeles, a new partner. The Center is participating with the University of California/Davis/Center for Diverse Healthcare Workforce in a Micro-aggression Study. Title of the study is “Seeking Health Equity by Understanding How to Support Underrepresented Health Professions Students ” Principal Investigator (PI): Kupiri Ackerman-Barger, PhD; Site PIs at Meharry: Katherine Y. Brown, EdD, and Paul D. Juarez, PhD. The study at Meharry will focus on the following examinations: • Determine if Black students attending historically Black colleges and universities experience micro-aggressions in their academic settings, and if so how. If students are experiencing micro-aggressions explore how they may be similar or different from Black and White students attending primarily White campuses. • Determine what works well in historically Black colleges and universities in relation to inclusive learning environments • Explore what challenges or concerns related to academic and career success may exist for health professions students at historically Black colleges and universities • Identify what health professions students at historically Black colleges and universities believe they need from their school and faculty to support their academic and career success Objective 2: Conduct two (2) system-level research projects out of four (4) projects in collaboration with the Project Officer in Year 4. Outcome: The Center has completed the systematic reviews on Affirming Care and Immunization Disparities. The Center will include a survey that will explore opinions of patients on each topic. IRBs for Affirming Care have been submitted for approval and IRB for the Immunization Disparities has been approved. Publications and Abstracts 1. Morris, M., Cooper, R.L., Ramesh, A., Tabatabai, M., Arcury, T.A., Shinn, M., Im, W., Juarez, P., Matthews-Juarez, P. Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review. BMC Med Educ. 19, 325 (2019) doi:10.1186/s12909-019-1727-3 2. Juarez, PD. Screening for Violent Tendencies in Adolescents - A Focus on Causes, Effects and Screening. (Vince Morelli, Ed.). Adolescent Health Screening: an Update in the Age of Big Data. Elsevier. 2019. 3. Morris, M., Cooper, R.L., Ramesh, A., Tabatabai, M., Arcury, T.A., Shinn, M., Im, W., Juarez, P., Matthews-Juarez, P. Preparing medical students to address the needs of vulnerable patient populations: Implicit bias training in U.S medical schools. Med.Sci.Educ. (2020). https://doi.org/10.1007/s40670-020-00930-3. Under Review 1. Cooper, R.L., Juarez, P., Morris, M., Edgerton, R., Brown, L.L., Mena, L., MacMaster, S.A., Collins, S., Matthews-Juarez, P., HRSA Academic Units Research Group. Recommendations for Increasing Physician Provision of Pre-Exposure Prophylaxis. Journal of Health Care for the Poor and Underserved (Submitted for review).

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2. Cooper, R.L. et al. Dynamics of Fatal Opioid Overdose by State and Across Time. August 2019. 3. Juarez, P., Ramesh, A., Cooper, R.L., Tabatabai, M., Arcury, T.A., Shinn, M., MatthewsJuarez, P. A Systematic Review of the Effectiveness of Interventions Designed to Teach Medical Students to Address Interpersonal Violence across the Life Course. Academic Medicine (Submitted for review). 4. Cooper, R.L., Tabatabai, M., Juarez, P., Ramesh, A., Morris, M.C., Edgerton, R., Arcury, T.A., Shinn, M., Mena, L., Matthews-Juarez, P. PrEP Training in Medical Schools in the United States. AIDS and Behavior (Submitted for Review). In Manuscript in Preparation 1. Ramesh, A., Juarez, P.D., Paul, M., Morris, M.C., Cooper, R.L., Tabatabai, M., Arcury, T.A., Shinn, M., Mena, L.A., Im, W., Brown, K.Y., Matthews-Juarez, P. Curricular Interventions in Medical Schools for Assessing Adverse Childhood Experience. Abstracts for Manuscript Development: 1. The Effect of Homelessness on Viral Suppression among HIV-positive Persons in an Underserved Metropolitan Area of the South: 5-Year Analysis: Vladimir Berthaud, Abosede Osijo, Maxine Chandler-Auguste, Marie T. Baldwin, Ronda Jennings, Paul Juarez, Patricia Matthews-Juarez, Derek Wilus, and Mohammad Tabatabai. 2. Title: Primary Care Training in Adverse Childhood Experiences (ACEs) among Lesbians, Gays, Bisexuals, Transgender and Questioning (LGBTQ), persons experiencing homelessness, and migrant farm worker: Gaps in Medical Education Authors: Paul D. Juarez, M. Paul; A Ramesh; P. Matthews-Juarez. 3. Title: Training medical students to identify, diagnose and treat opioid use disorder (OUD) among vulnerable populations, specifically, persons identifying as Lesbians, Gay, Bisexual, Transgender, and Questioning (LGBTQ), persons experiencing Homelessness and migrant farm workers. Author: M Paul, RL Cooper, A Ramesh, P Juarez, P Matthews-Juarez 4. Title: Immunization disparities among vulnerable populations: What medical students need to know.Author: Paul D. Juarez, Deliana Garcia, Tom Arcury, Patricia Matthews-Juarez 5. Title: Transforming Primary Care Training: Collective Impact of a Community of Practice Model. Author: Matthews-Juarez, P., Juarez, P., Brown, K.Y.

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COMPREHENSIVE OVERVIEW OF THE NCMEDR PRODUCTS – YEARS 1-4

COP DISSEMINATION POWERPOINT https://drive.google.com/file/d/1g4DcqfIq4xYbhW0QpwYreGdKWKcqAeYK/view?usp=sharing

2017-2018 COMMUNITIES OF PRACTICE PRODUCTS https://drive.google.com/drive/folders/1gvAiqxtr3Fbpbv5K4c5JE0Z-rDGF7hP_?usp=sharing

2018-2019 COMMUNITIES OF PRACTICE PRODUCTS https://drive.google.com/drive/folders/1PB4JVAIxsWeJeUQCog1JrVfivlOYNrIp?usp=sharing

2019-2020 COMMUNITIES OF PRACTICE PRODUCTS https://drive.google.com/drive/folders/12jgdmDSJi4HRssEBkNWNcRNWsXRWZYOo?usp=sharing

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FUNDED YEARS 2016 – 2021

The National Center for Medical Education Development and Research (NCMEDR) Profile, Products, and Outcomes Project Director: Pat Matthews-Juarez, PhD Center Director: Paul D. Juarez, PhD Scientific Research Director: Aramandla Ramesh, PhD Research Team: Robert L. Cooper, PhD, Matthew Morris, PhD, Mohammad Tabatabai, PhD Research Assistant; & Michael Paul, MSPH Director of Community of Practice and Dissemination: Katherine Y. Brown, EdD; & Wansoo Im, PhD Consultants: Leandro Mena, MD, MPH, Beth Shinn, PhD, & Thomas Arcury, PhD CoP Curriculum Development members: Drs. Asa Radix, Jayne Reuben, and Armin Weinberg, Cheryl Holder The National Center for Medical Education Development and Research (NCMEDR) is an academic unit (AU) in the Department of Family and Community Medicine at Meharry Medical College developed under a cooperative agreement with HRSA (UH to evaluate the evidence-base for primary care interventions targeting vulnerable populations in order to transform primary care training and clinical practice. As a national center the NCMEDR focuses on three vulnerable populations, specifically lesbian, gay, bisexual, transgender, questioning (LGBTQ), persons experiencing homelessness, and migrant farm workers. The NCMEDR is one of six HRSA Funded AU’s. The six AU’s are: » » » » » »

Meharry Medical College - Meeting the Needs of Vulnerable Populations Harvard University - Integrating Oral Health Into Primary Care Northwestern University - Addressing the Social Determinants of Health University of California - UC Davis - Diverse Healthcare Workforce University of Pennsylvania - Integrating Mental Health Into Primary Care University of Washington - Training for Rural Practice

The NCMEDR objectives are to: » Establish and sustain an academic unit in the Department of Family and Community Medicine over five years. » Conduct two (2) systems-level research projects each year in collaboration with HRSA staff in Years 1-5 for a total of 10 over the duration of the project. » Disseminate research findings to academic, primary care training, and health care professions audiences about best practices, available evidence, and evaluation tools of effective interventions for vulnerable populations. » Establish Communities of Practice (CoP) to assess the needs of vulnerable populations (LGBTQ, migrant workers, and homeless persons) and translate research findings into primary care training and practice guidelines. To accomplish its goals the NCMEDR 1) conducts systems-level research of evidence-based interventions for vulnerable populations to inform primary care training specifically two research topics per year, 2) disseminates best practices and resources to primary care providers and trainees across to improve clinical outcomes among three vulnerable populations, and 3) established three (3) communities of practice that promote the widespread enhancement of a high quality, primary care workforce that participate or lead clinical practices that will produce better health outcomes for LGBTQ, persons experiencing homelessness, and migrant farm worker populations.

RESEARCH The NCMEDR has completed a total of ten (10) research studies over the five year period. The two research topics per year that have been completed over the five-year period are: » » » » »

Year 1: Physician Implicit Bias and Pre-Exposure Prophylaxis (PrEP) Year 2: Interpersonal Violence Across The Life Course and Adverse Childhood Experiences Year 3: Opioid Misuse and Sexual Violence Year 4: Gender Affirming Care and Immunization Disparities Year 5: Mental Health and Telehealth

The research process and procedures include conducting systematic review of literature. There were two guiding research questions for the Center. There were: 1) How are medical schools training students to address the needs of vulnerable populations? 2) What are best practices in medical education relative to vulnerable populations?

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APPROACH, METHODOLOGY AND PRODUCTS A four-step process has been employed. » » » »

Step 1: Worked with Resource Librarian to identify search parameters. Step 2: Adapted systematic review criteria (PRISMA, Strobe, Core Q, etc.). Step 3: Applied systematic review guidelines. Step 4: Worked with CoP/Dissemination Core to translate and disseminate research findings.

The unique aspect of the NCMEDR from its outset was to develop and implement three (3) communities of practice of national thought leaders, content experts, and stakeholders (patients who were members of the three (3) vulnerable populations (LGBTQ, persons experiencing homelessness, and migrant farm workers) to comment and provide feedback on the design of the research studies, the findings, final curricular products, and results/outcome evaluation and assessment of the success of the center in meeting its goals and objectives. Over a five (5) year period, the comprehensive and holistic approach and methodology undertaken by the Center had produced the following: » Fourteen (14)peer-reviewed publications; » Three (3) book chapters: Interpersonal violence (Juarez); Community of practice( Brown, Matthews-Juarez, Ramesh, and Suara); Emerging Cultural Issues in Medicine (Brown, Matthews-Juarez, and Juarez. » Four (4) national surveys and questionnaires on medical education and clinical practices; » Ten (10) policy briefs (one for each of the 10 research topics over the five-year period; » Fifty (50) scholarly presentations including presentations at the Research Centers for Minority Institutions, Beyond Flexner, AAMC and Xavier Health Disparities Conferences; » Four (4) clinical vignettes on Transgender Perspectives on Clinical Treatment and Implicit Bias; » Six (6) published blogs on medical education, primary care training, and clinical services; » Five (5) comprehensive NCMEDR CoP Conference Booklets that include a description of all of the research studies, policy briefs, and recommended readings by topic; and » Twenty-four webinars with 637 attendees on curriculum development, bio-ethics, primary care training issues for medical students and clinical practice issues for health care providers; » CoP TV with a 230 topics on ACEs, Interpersonal violence, affirming care, immunizations, HIV and PrEP, implicit bias, and opioid misuse. » Two radio presentations: Vulnerable populations and cancer care.

COMMUNITIES OF PRACTICE AND DISSEMINATION: IMPACT Our approach to the CoP model included four steps: » » » »

Step 1: Recruit and sustain a diverse team of academic, clinical, professional, policy, and lay audiences. Step 2: Conduct regular forums with CoP members to identify, translate, and disseminate evidence based, best practices. Step 3: Identify best strategies and venues for targeting different populations. Step 4: Evaluate effectiveness of strategies in reaching targeted audiences. The NCMEDR had four target audiences to disseminate research findings about best practices and effective interventions for vulnerable populations using the CoP and the diffusion and communication models.

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The Center identified four (4) audiences for dissemination: » Audience 1: Academicians - publications, abstracts, presentations (posters, podium and webinars), Curriculum Modules and educational tools. » Audience 2: Health Care Professionals - traditional media, website, newsletters, listserv, social media products. » Audience 3: Lay Audiences – The general public interested in primary care education and clinical services: Social media, Facebook, YouTube, Twitter, Instagram, etc. » Audience 4: Accrediting bodies, legislators, regulators, advocates community, health professions, legal and public health professionsPolicy Briefs. Using the illustration below, one can see that a community of practice (CoP) is a group of people who share a craft or a profession. The concept was first proposed by a cognitive anthropologist Jean Lave and educational theorist Etienne Wenger-Trayner, PhD, in their 1991. This schema appeared in the book, Situated Learning (Lave & Wenger). Wenger expanded the concept of community of practice in his book, Communities of Practice (Wenger 1998).

Lave & Wenger 1991

COP METHODS OF DISSEMINATION: The Center uses the various tools for dissemination of findings, results, information, and products: » » » » » »

Scholarly Articles Conference Presentations Policy Briefs Webinars NCMEDR Website Social Media » » » »

YouTube Twitter Facebook Instagram

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USE OF SOCIAL MEDIA/YOUTUBE AND WEBSITE FOR DISSEMINATION OF PRODUCTS: » Online Repository » Newspapers and Radio » 12 Channels, 228 Videos » » » » » » » » »

Channel 1: Learn About CoP TV and Communities of Practice: 12 Videos Channel 2: Persons Experiencing Homelessness: 10 Videos Channel 3: Migrant Farm Workers: 10 Videos Channel 4: LGBTQ Resources: 10 Videos Channel 5: Tools for Behavioral Health / Opioid and Substance Use Disorders in Medical Education: 15 Videos Channel 6: Motivational Interviewing for Medical Education: 21 Videos Channel7: Medical Education, Clinical Transformation, and Workforce Development: 23 Videos Channel 8: Meharry Medical College Channel 9: Tennessee AHEC Scholars: Collaborative Presentations at Hillwood High School on vulnerable populations and the Use of Social Media » Channel 10: Behavioral Health Workforce Education Training focusing on Vulnerable Populations » Channel 11: College-wide PCMH at Meharry » Channel 12: Coronavirus Disease 19 The NCMEDR website serves as an online repository of information for stakeholders including medical school faculty interested in curriculum development, use of communities of practices to transform medical education and clinical practices. It includes a community of practice (CoP) Blog, CoP YouTube Channel link, program booklets from the annual communities of practice conference, and identifies and provides curriculum guides, toolkits, and education models to primary care faculty to train residents and health professions students to deliver high quality, cost-effective, patient-centered care to vulnerable populations in underserved communities.

OUR NATIONAL, STATE, AND LOCAL PARTNERS ARE: » Health Resources and Services Administration » Fenway Institute National LGBT Health Education Center » National Healthcare for the Homeless Council » Migrant Clinicians Network » Mayo Clinic Social Media Network » Downtown Women’s Center » Tennessee Department of Health/Office of Minority Health and Disparities Elimination » T3 (Think, Teach, Transform) » Greater than AIDS, Streetworks, MashUp Nashville, National Community Mapping Institute, CWPCMH Training Program, Behavioral Health Workforce Education and Training (BHWET) Program, Cherokee Health Systems » Consumers

COP CONFERENCES: 2017-2021 There have been five CoP conferences to date. Each conference has a theme and convenes thought leaders and content experts. The conference themes: » » » » »

2017 - Curriculum and Training: Practice Transformation in the Age of Training Millennials 2018 - Medical Education and Clinical Transformation: A Curriculum Pathway Forward 2019 - Transforming the Culture of Medical Education 2020 - Transforming Medical Education and Clinical Practice to Better Address the Health Care Needs of Vulnerable Populations 2021 -The Future of Medical Education and Clinical Services Transformation: Meeting the Needs of Vulnerable Populations in 2030

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2017: CURRICULUM AND TRAINING: PRACTICE TRANSFORMATION IN THE AGE OF TRAINING MILLENNIALS

The speaker was Veronica Mallett, MD, Dean of the School of Medicine at Meharry Medical College (Second Picture from Left)

2018: MEDICAL EDUCATION AND CLINICAL TRANSFORMATION: A CURRICULUM PATHWAY FORWARD

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2019: TRANSFORMING THE CULTURE OF MEDICAL EDUCATION

2020: THE CROSSROADS BETWEEN CLINICAL PRACTICE AND MEDICAL EDUCATION: ADDRESSING THE HEALTH NEEDS OF VULNERABLE POPULATIONS. CoP 2020 Annual Meeting: Key Note Speakers: Speakers in 2020 by virtualization were Etienne Wenger-Trayner, PhD and Beverly Wenger-Trayner. The focus was on social networks and values held and implemented by community groups and stakeholders. Past NCMEDR highlights include this meeting with Dr. Etienne Wenger-Trayner and hosting a webinar with Dr. Etienne Wenger-Trayner and Beverly WengerTrayner, social learning theorists. Dr. Etienne WengerTrayner is a pioneer, thought leader, and consultant in the social learning theory of communities of practice. Wenger-Trayner’s contributions shaped the field of artificial intelligence in education. He is known for the social learning theory of communities of practice. At the invitation of the NCMEDR, Dr. Wenger-Trayner was the guest speaker at the 2018 HRSA AU Annual Meeting in which other 5 National AU Centers attended.

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Town Hall Meeting: Innovations in Medical Education: Lessons Learned for Preparing Providers for Future Public Health Crisis Presenters were: Clockwise: C. Alicia Georges, EdD, RN, Professor and Chair of Nursing, Lehman College, School of Nursing, City University of New York; Topic: Interprofessionalism and the Continuum of Care in the Face of Crisis; Johnnie L. Early, PhD, Dean, Florida A. M. University, School of Pharmacy; Topic: The Role of Allied Health Professionals in Clinical Transformation; and William McDade, MD, PhD, Chief Diversity and Inclusion Officer, Accreditation Council on Graduate Medical Education; Topic The Future of Undergraduate Medical Education in Forecasting New Competences for Clinical Transformation.

2021: INTERSECTIONALITY: MEDICAL EDUCATION, CLINICAL PRACTICE, AND HEALTH EQUITY Our 2021 Speaker is David A. Acosta, MD, provides strategic vision and leadership for the AAMC’s diversity and inclusion activities across the medical education community, and leads the association’s Equity, Diversity, and Inclusion unit. Dr. Acosta, a family medicine physician, joined the AAMC from the University of California (UC), Davis School of Medicine where he served as senior associate dean for equity, diversity, and inclusion and associate vice chancellor for diversity and inclusion and chief diversity officer for UC Davis Health System. He previously served as the first chief diversity officer at the University of Washington (UW) School of Medicine (SoM), where he established the Center for Equity, Diversity and Inclusion, and was the founder of the UW SoM Center for Cultural Proficiency in Medical Education. Dr. Acosta earned his bachelor’s degree in biology from Loyola University and his medical degree from the UC, Irvine, School of Medicine. He completed his residency training at Community Hospital of Sonoma County in Santa Rosa, California, an affiliate of UC San Francisco School of Medicine, and a faculty development fellowship at the UW Department of Family Medicine.

NUMBER OF THOUGHT LEADERS AND CONTENT EXPERTS: A total of 289 thought leaders and content experts have participated in the CoP Conferences over the five-year period. With feedback from CoP members even during the COVID19 pandemic, the center demonstrated flexibility, resilience, and the ability to meet goals. Notwithstanding videoconference CoP Meetings, convening a virtual 4th year and 5th year NCMEDR CoP Conference, utilizing technology for the 3 CoP breakout rooms, and international participation in virtual initiatives, the NCMEDR maintained integrity of the conference, while collaborating with its members. The Center has also been able to participate in Twitter chats, webinars, and utilize technology to engage CoP members. The webinars have hosted over 690 participants The CoP members have referred new members and demonstrated their commitment to the center. The CoP model proved to be beneficial. The center’s implementation of CoPs has resulted in the continued success and sustainability of the Center.

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SOCIAL MEDIA: Twitter, Instagram, Facebook, and You Tube Social Media has been utilized as a strategic tool to disseminate information. The center website http://www.ncmedr.org has had a total of 1,407,597 visits over the 5 year period. The center maintained two Twitter accounts. The first account Primary Care Training COP (@PCTCoP) had 300,879 impressions from October 2019 to May 2021. The second Twitter account @ NCMEDR_Meharry had 488,506 impressions from August 2017 to May 2021. There were a total of 789,385 impressions in tweets. The Center maintains a YouTube Channel that has a total of 228 videos. The social media pages for the Center are used to connect with the various audiences and include sharing information related to research findings, outcomes, and products.

NCMEDR ABSTRACTS & PUBLICATIONS ABSTRACTS (POSTERS/PRESENTATIONS) 1. Cooper RL, Juarez P, Mathews-Juarez P, Morris M, Tabatabai M, Ramesh A, Im W. Examining differences in HIV care cascade adherence and health outcomes between African American MSM and MSW. Abstract presented at the 10th Xavier University Health Disparities Research Conference, New Orleans, LA, March 16-18, 2017. 2. Morris M, Ramesh A, Cooper RL, Tabatabai M, Im W, Juarez P, Matthews-Juarez P. Strategies to reduce physician bias and promote culturally competent care for LGBT patients: A systematic review of interventions for health care providers. Abstract presented at the 10th Xavier University Health Disparities Research Conference, New Orleans, LA, March 16-18, 2017. 3. Ramesh A, Kumar A, Juarez P, Juarez P-M, Hood DB, Nyanda AM. Polycyclic aromatic hydrocarbon levels in serum samples. RCMI Translational Science Meeting, Washington, DC October 30-November 2, 2017. 4. Cooper RL, Juarez PD, Edgerton R, Ramesh A, Tabatabai M, Matthews-Juarez P. Modeling disparities in opioid overdose deaths: Using data from a national health crisis to train medical students in health disparities. Abstract of paper presented in the Beyond Flexner Meeting April 9, 2018. 5. Ramesh A, Matthews-Juarez P, Paul M, Watson J, Juarez PD. Interpersonal violence across the life course. Abstract presented at the 11th Xavier University Health Disparities Meeting, New Orleans, LA, April 19-20, 2018. 6. Ramesh A, Nyanda AM, Hood DB, Juarez PD, Juarez PM. Environmentally-driven health disparities: the need for toxicovigilance. Abstract presented at the 11th Xavier University Health Disparities Meeting, New Orleans, LA, April 19-20, 2018. 7. Juarez PD, Matthews-Juarez P. Advancing Health Equity: Translating Research into Policy for Primary Care Training: The NCMEDR Experience. AAMC meeting, Orlando, FL April 24, 2018. 8. Ramesh A, Paul M, Dixon T, Morris M, Cooper R, Tabatabai M,

Im W, Brown K, Juarez PD, Matthews-Juarez P. Educational Interventions for Treating Adverse Childhood Experience. Abstract presented at the 12th Xavier University Health Disparities Meeting, New Orleans, LA, April 8-10, 2019. 9. Paul M, Dixon T, Ramesh A, Morris M, Cooper R, Tabatabai M, Im W, Brown K, Juarez PD, Matthews-Juarez P. Measures for Enhancing Interpersonal Violence Education in Medical Schools. Abstract presented at the 12th Xavier University Health Disparities Meeting, New Orleans, LA, April 8-10, 2019. 10. Cooper RL, Brown LL, Tabatabai M, Haas DW, Shepherd BE, Myers HF, Edgerton RD, Bonny C, Watson JA, Berthaud V. Stress, Acceptance, and ARV Adherence in Black men with HIV. Abstract presented at the 12th Xavier University Health Disparities Meeting, New Orleans, LA, April 8-10, 2019. 11. Bethaud V, Johnson L, Jennings R, Chandler-Auguste M, Osijo A, Baldwin M, Juarez PD, Matthews-Juarez P, Wilus D, Tabatabai M. The effect of homelessness of the HIV care continuum in an underserved metropolitan area of the south: 5-year analysis. Abstract presented at the American Public Health Association Annual Meeting, October 24, 2020. 12. Tabatabai M, Bailey S, Matthews-Juarez P, Bahri N, Cooper RL, Wilus D, Juarez PD. Racial disparities in kidney carcinoma and its relationship to the histological types of disease: A Hypertabastic survival analysis. Abstract presented in the RCMI Annual Meeting, December 1, 2020. 13. Paul MJ, Cooper RL, Ramesh A, Tabatabai M, Brown KY, Juarez PD, Matthews-Juarez P. Opioid Use Disorder Treatment Training for Medical Students and Residents. Abstract presented in the 13th Xavier University Health Disparities Meeting, New Orleans, LA, April 7-9, 2020. 14. Juarez PD, Ramesh A, Paul MJ, Cooper RL, Tabatabai M, Brown KY, Matthews-Juarez P. Medical Education Efforts to Address Sexual Violence. Abstract presented in the 13th Xavier University Health Disparities Meeting, New Orleans, LA, April 7-9, 2020.

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NCMEDR Profile, Products, and Outcomes 15. Cooper RL, Ramesh A, Juarez PD, Paul MJ, Tabatabai M, Brown KY, Matthews-Juarez P. Interventions to Train Health Professionals on Opioid Use Disorder. Abstract presented in the 14th Xavier University Health Disparities Meeting, New Orleans, LA, April 7-8, 2021. 16. Cooper RL, Ramesh A, Radix AE, Juarez PD, Belton A, Holder CL, Reuben JS, Brown KY, Mena L, Matthews-Juarez P. Affirming and Inclusive Care Training for Medical Students and Residents. Abstract presented in the 14th Xavier University Health Disparities Meeting, New Orleans, LA, April 7-8, 2021. 17. Juarez PD, Ramesh A, Cooper RL, Paul MJ, Tabatabai M, Brown KY, Matthews-Juarez P. Medical Education Efforts to address Interpersonal Violence. Abstract presented in the 14th Xavier University Health Disparities Meeting, New Orleans, LA, April 7-8, 2021. 18. Ramesh A, Cooper RL, Juarez PD, Walter AW, Reuben JS, Thorum K, Brown KY, Paul MJ, Hood DB, Matthews-Juarez P. Addressing Immunization Disparities through Educational Interventions. Abstract presented in the 14th Xavier University Health Disparities Meeting, New Orleans, LA, April 7-8, 2021.

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5th Annual Communities of Practice Conference 19. Ramesh A, Cooper RL, Juarez PD, Offodile RS, Walter AW, Reuben JS, Thorum K, Brown KY, Hood DB, Matthews-Juarez P. Assessment of Educational Interventions for Delivering Health Care through Telehealth. Abstract presented in the 14th Xavier University Health Disparities Meeting, New Orleans, LA, April 7-8, 2021. 20. Brown KY. Transforming Primary Care Training: Collective Impact of a Community of Practice Model: National center for Medical Education, Development & Research. Podium Presentation in the 14th Xavier University Health Disparities Research Conference, New Orleans, April 8, 2021.

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PUBLICATIONS 1. Juarez, PD (2019). Screening for violent tendencies in adolescents - A focus on Causes, effects and screening. (Vince Morelli, Ed.). Adolescent Health Screening: an Update in the Age of Big Data. Elsevier Publishers, London. 2. Morris M, Cooper RL, Ramesh A, Tabatabai M, Arcury TA, Shinn M, Im W, Juarez PD, Matthews-Juarez P (2019). Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review. BMC Med Educ. 19(1):325. 3. Morris MC, Cooper RL, Ramesh A, Tabatabai M, Arcury TA, Shinn M, Im W, Juarez PD, Matthews-Juarez P (2020). Preparing medical students to address the needs of vulnerable patient populations: Implicit bias training in US medical schools. Medical Science Educator 30:123–127. 4. Juarez PD, Ackerman-Barger (2020). Transforming primary care through medical education to promote health equity. J. Health Care Poor Underserved 31(4): vi-vii. 5. Matthews-Juarez P, Brown KY, Suara HA (2020). Communities of practice: transforming medical education and clinical practice for vulnerable populations. J. Health Care Poor Underserved 31(4): 18-25. 6. Cooper RL, Ramesh A, Juarez PD, Edgerton R, Paul MJ, Tabatabai M, Brown KY, Matthews-Juarez P (2020). Systematic review of opioid use disorder treatment training for medical students and residents. J. Health Care Poor Underserved 31(4): 26-42. 7. Juarez P, Ramesh A, Cooper RL, Tabatabai M, Brown KY, Arcury TA, Shinn M, Paul M, Matthews-Juarez P (2020). A systematic review of the effectiveness of interventions designed to teach medical students to address interpersonal violence across the life course. J. Health Care Poor Underserved 31(4): 43-67. 8. Ramesh A, Juarez PD, Paul MJ, Morris MC, Cooper RL, Tabatabai M, Arcury TA, Shinn M, Brown KY, Matthews-Juarez P (2020). Curricular interventions in medical schools for assessing adverse childhood experience: a systematic review. J. Health Care Poor Underserved 31(4): 68-90. 9. Ravenna PA, Bream KDW, Fancher T, Juarez PD, Klusaritz HA, Matthews-Juarez P, Persell SD, Phillips RS, Riedy C, Patterson DG (2020). Who,what,and where: transforming primary care education to advance health equity. J. Health Care Poor Underserved 31(4): 128-138. 10. Doubeni CA, Fancher TL, Juarez PD, Riedy C, Stephen, Persell Sd, Sandvold I, Schmitz D, Sochalski J (2020). A framework for transforming primary care health care professions education and training to promote health equity. J. Health Care Poor Underserved 31(4); 193-207. 11. Juarez PD, Tabatabai M, Burciaga Valdez R, Hood DB, Im W, Mouton C, Colen C, Al-Hamdan MZ, Matthews-Juarez P, Lichtveld MY, Sarpong D, Ramesh A, Langston MA, Rogers GL, Phillips CA, Reichard JF, Donneyong MM, Blot, W. (2020). The effects of social, personal, and behavioral risk factors and PM2.5 on cardiometabolic disparities in a cohort of community health center patients. Int. J. Environ. Res. Public Health, 17, 3561.

12. Juarez PD, Hood DB, Song M-A, Ramesh A (2020). Use of an exposome approach to understand the effects of exposures from the natural, built, and social environments on cardiovascular disease onset, progression and outcomes. Frontiers in Public Health 12; 8: 379. 13. Donneyong MM, Chang TJ, Jackson JW, Langston MA, Juarez PD, Sealy-Jefferson S, Lu B, Im W, Valdez RB, Way BM, Colen C, Fischer MA, Salsberry P, Bridges JFP, Hood DB (2020). Structural and Social Determinants of Health Factors Associated with County-Level Variation in Non-Adherence to Antihypertensive Medication Treatment. Int J Environ Res Public Health. 17(18):6684. 14. Cooper RL, Thompson J, Edgerton R, Watson J, MacMaster SA, Kalliny M, Huffman MM, Juarez P, Mathews-Juarez P, Tabatabai M, Singh KP (2020). Modeling dynamics of fatal opioid overdose by state and across time. Prev Med Rep. 20:101184. 15. Mpofu E, Ingman S, Matthews-Juarez P, Rivera-Torres S, Juarez PD (2021). Trending the evidence on opioid use disorder (OUD) continuum of care among rural American Indian/Alaskan Native (AI/AN) tribes: A systematic scoping review. Addict Behav. 114:106743. doi: 10.1016/j.addbeh.2020.106743. 16. Cooper RL, Brown LL, Tabatabai M, Haas DW, Shepherd BE, Myers HF, Edgerton RD, Bonny C, Watson JA, Berthaud V (2021). The Effects of Perceived Stress and Cortisol Concentration on Antiretroviral Adherence When Mediated by Psychological Flexibility Among Southern Black Men Living with HIV. AIDS Behav. 25(2):645-652. 17. Tabatabai M, Bailey S, Bursac Z, Tabatabai H, Wilus D, Singh KP (2021). An introduction to new robust linear and monotonic correlation coefficients. BMC Bioinformatics. 22(1):170. 18. Brown KY, Ramesh A, Juarez PD, Matthews-Juarez P (2021). Innovation in Medical Education: A Communities of Practice Approach. In: Joosten Hagye D, Khalili H (Ed). Interprofessional Education and Collaborative Practice- micro, meso, and macro approaches across the lifespan. Cognella, Inc. San Diego, CA (in press). 19. Juarez PD, Hood DB, Song M-A, Ramesh A (2021). Applying an Exposome-Wide (ExWAS) Approach to Latino Cancer Disparities. In: Ramirez AG, Trapido EJ (Eds.). Advancing the Science of Cancer in Latinos. Springer Nature, Cham, Switzerland (in press). 20. Cooper RL, Juarez PD, Morris MC, Ramesh A, Edgerton R, Brown L, Mena L, Collins S, Matthews-Juarez P, Tabatabai M, Brown KY, Paul MJ, Im W, Arcury TA, Shinn M. Recommendations for increasing physician provision of pre-Exposure Prophylaxis: Implications for Medical Student Training. INQUIRY: The Journal of Health Care Organization, Provision, and Financing (2021).

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About the Speakers & Content Experts

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SPEAKERS, MODERATORS / FACILITATORS, AND CONTENT EXPERTS David A. Acosta MD – p. 18 As chief diversity and inclusion officer, David A. Acosta, MD, provides strategic vision and leadership for the AAMC’s diversity and inclusion activities across the medical education community, and leads the association’s Diversity Policy and Programs unit. A board-certified physician of family medicine, Dr. Acosta joined the AAMC from the University of California (UC), Davis School of Medicine where he served as senior associate dean for equity, diversity, and inclusion and associate vice chancellor for diversity and inclusion and chief diversity officer for UC Davis Health System. He previously served as the inaugural chief diversity officer at the University of Washington (UW) School of Medicine, where he established a rural health fellowship program for Tacoma Family Medicine, a residency program affiliated with the UW Department of Family Medicine.

Donald J. Alcendor PhD – p. 19 Dr. Alcendor completed his post-graduate studies at the NIH and Johns Hopkins University, in Baltimore Maryland in departments of Molecular Virology and Viral Oncology respectively. As a graduate student at the University of California at Davis he received the Patricia Roberts Harris Graduate Fellowship, was a University of California Davis Mentorship Fellow, a National Heart Lung and Blood Institute Pre-doctoral Fellow, a National Heart Lung and Blood Institute Post-doctoral Fellow, a Floyd and Mary Schwall, Dissertation Fellow, a National Heart Lung and Blood Institute Spring Fellow, and a recipient of the Merck Special Service Award. Dr. Alcendor was also a research consultant to the Viral Vector Core Laboratory in Viral Oncology, at Johns Hopkins, and was a Cytomegalovirus Expert for the FDA, Division of Vaccine Injury and Compensation Program for the Department of Health and Human Services in Rockville, Maryland. He has also served as a summer mentor for the Leadership Alliance for the American Society of Microbiology. He was a mentor for the FDA Office of Minority Health, Health Disparities Fellowship. He was also selected as a Minority Scholar in Cancer Research by the American Association for Cancer Research (AACR). He received the Nashville Business Journal Health Care Hero Award in Research. He was selected as a member of the American Society for Microbiology (ASM) list of distinguish minority microbiologist. He was also a committee member on the independent Research Evaluation and Decision Panel (REDP) for the AIDS Cancer and Specimen Resource of the NCI-AIDS Malignancy Program. He was a Brain-on-chip investigator in partnership with Vanderbilt and the Cleveland Clinic. He was funded to develop the Blood-Retinal-Barrier on a Chip. He is a Research Liaison for the FDA Office of Minority Health with Meharry Medical College. He was a consultant and voting member on the FDA Antimicrobial Drug Advisory Committee. He was selected as an expert grant reviewer for the Florida Department of Health’s Biomedical Research Programs through the Oak Ridge Associated Universities and Department of Energy. He is an Associate Director of the Vanderbilt Short Term Training Program for minority students. He is also a member of the Vanderbilt Pre3 Initiative (Preventing Adverse Pregnancy Outcomes & Prematurity). He is a voting member of Vanderbilt Institute for Clinical and Translational Research (CTSA) Scientific Review Committee. He is Technical Advisory Group

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member for the Tennessee Health Care Innovation Initiative Episodes of Care, “HIV Outpatient Skin and Soft Tissue Infection (SSTI) for the State of Tennessee. He was the Principal Investigator and Director of the Community Outreach Core for Project SAVED, a CDC funded HIV capacity building assistance initiative. He was selected as an expert advisory panel member for the American Lung Association COVID-19 Action Initiative. He is a member of the American Lung Association Scientific Advisory Board. He was the director of the Zika Pathogenesis Working Group based at Meharry. He was an Associate Director for the Continuum of Care Scientific working group for the Tennessee Center for AIDS Research and he organized the 1st HIV/AIDS Awareness Summit for Teens sponsored by the HIV Center at Meharry. Finally, he is a member of several editorial boards and committees associated with infectious disease and has been an invited speaker to key national science conferences.

Thomas A. Arcury PhD – p. 19, 20 Dr. Arcury is Professor of Family and Community Medicine, and Director of the Center for Worker Health, Wake Forest School of Medicine. He is a medical anthropologist and public health scientist with a research agenda focused on improving the health of rural and minority populations. Since 1996, he has participated in a research program on health and justice among migrant and seasonal workers. Undertaken within a community-based participatory research framework, this program has included empirical studies, developed educational programs, and collaborated with advocacy groups to change environmental and occupational health policy.

Allyson S. Belton MPH – p. 22, 23 Allyson S. Belton, MPH is the Director of Education and Training for the Satcher Health Leadership Institute at Morehouse School of Medicine. In this role, she is responsible for the design and evaluation of health equity-based leadership training programs for diverse learners, in alignment with the SHLI priority and focus areas. Additionally, she supports research addressing health inequities, examining approaches across all levels within the social context, including systems and policies. She holds a Bachelor of Science in Biology from Spelman College and a Master of Public Health with a concentration in Health Promotion and Behavior from Georgia State University.

Katherine Y. Brown EdD – p. 18, 20, 23 Dr. Katherine Y. Brown is Assistant Professor in Department of Family and Community Medicine at Meharry Medical College. She is Director, Communities of Practice and Dissemination, for National Center for Medical Education, Development and Research; Director of Communications, Tennessee Engaged Alliance Against COVID-19. She is a highly sought-after international speaker and social media strategist. She has 25 years of professional experience assisting academic institutions and organizations in innovative dissemination strategies. She has been recognized in Forbes, is a National Spokesperson for Learn CPR America. She founded the Dr. Katherine Y. Brown (KYB) Leadership Academy to train collegiate and high school students on

5th Annual Communities of Practice Conference global leadership and careers in health care. She is an accomplished T E D x Speaker.

Lawrence Bryant PhD, RRT – p. 22 As a member of the Cobb/Douglass Behavioral Workgroup, Dr. Bryant brings a plethora of experiences dealing with substance use disorders through clinical practice, policy, and research. He has been successful in developing and implementing a statewide strategic plan for the state of Georgia in response to the opioid and prescription drug overdose epidemic. As a part-time Assistant Professor at Kennesaw State University, Health Promotion Department, Dr Bryant has received funding from The Georgia Department of Public Health to do a needs assessment in support of the Statewide Strategic Plan for Opioid Abuse. Dr Bryant just received certification in contact tracing and plans to utilize this knowledge to train other in this technique. Dr Bryant continues to publish in the field of public health and holds dual positions in both public health and psychology at Capella University. Dr Bryant is also a registered respiratory therapist, fighting on the front lines of the Covid-19 pandemic in the field of pediatrics

Janeth Ceballos Osorio MD – p. 22, 23 Janeth Ceballos Osorio, MD, FAAP, is an Associate Professor of Pediatrics at the University of Kentucky. She is the director of Clínica Amiga, a Pediatric Medical Home for Hispanic/Latinx families in Lexington, where she provides tailored primary care services to this community including a parent support group for families with children with special health care needs and monthly health education Podcast in Spanish. Dr. Ceballos also leads immigrant health efforts at the state level as co-chair of the Immigrant Child Health Task Force at the KY Chapter of the American Academy of Pediatrics.

Millard D. Collins Jr. MD,FAAFP – p. 18 Millard Darnell Collins, Jr. graduated from Xavier University of Louisiana in 1997 with a B.S. in Chemistry, then pursued a career in medicine at Meharry Medical College. Since graduating from Meharry Medical College, and completing training there in Family Medicine (board certified since 2004), Dr. Collins has worn many hats, including Clerkship Director, Residency Program Director, Associate Dean of Student & Academic Affairs, and currently serves as Chair and Associate Professor in the Department of Family & Community Medicine. In addition to his efforts at Meharry, he also has completed a Mini Fellowship in Geriatrics at UCLA (2008) and is a Harvard Macy Scholar (2010). Dr. Collins has an enthusiastic and innovative approach to curriculum design and clinical practice. Despite the tremendous administrative duties assigned, he has continued clinical interest ranging from inpatient and outpatient medicine, women’s health, geriatrics, and addiction. Meharry Medical College is a place he proudly calls home. Having spent years as a clinician with a busy practice and as a passionate professor of medicine, Dr. Collins spends his days as a versatile administrator, mentor to many students, residents and junior faculty, and letting the local Nashville community and beyond know of his passion for serving God through worship of mankind. It is indeed his

About the Speakers & Content Experts hope to apply his innovative approach to problem solving to the larger societal needs surrounding health disparities.

Robert Lyle Cooper PhD – p. 21 Dr. Cooper is an assistant professor and the founder and Director of the Meharry Family Medicine Addiction Treatment Clinic. He has over 20 years of experience as a behavioral interventionist. He is an experienced educator having developed a substance abuse counseling certificate program at Spalding University and a assisting in the development of the Doctorate of Clinical Social Work Program at the University of Tennessee. He is also an accomplished researcher having been awarded 14 federally funded grants, and publishing over 40 articles addressing substance use disorder, infectious disease, and health disparity related topics.

Marvin L. Crawford MD, MDiv – p. 22 Dr. Marvin Luther Crawford is an Associate Professor of Clinical Medicine and Director of Student Undergraduate Medical Education at Morehouse School of Medicine. He is the Pastor of First Saint Paul AME Church in Lithonia, Georgia. Dr. Crawford has centered his spiritual energies into encouraging the greatest of these to help and the least of these to hope. In all of his pastorates, food banks, educational assistance, health care education, economic empowerment, youth development, substance abuse intervention, housing and crime prevention have been the central point of his ministry. Dr. Crawford is a superb teacher and has received several awards during his 29-year career. Dr. Crawford is noted for his ability to incorporate spirituality into patient care and is one of the nation’s authentic experts in this area.

James Cruz MD – p. 19 Dr. Cruz has dedicated his career to serving California’s diverse communities of color by developing clinical training programs and placement of physicians to meet California’s demand for healthcare in physicianshortage areas. A forward thinker, he successfully organized and led 3 robust Family Practice Residency Programs in collaboration with the University of California, State and local agencies to deliver quality healthcare, and address healthcare inequities in low income communities in Northern, Central and Southern California. Dr. Cruz was the recipient of California’s Office of Statewide Health Planning and Development (OSHPD) first annual Minorities in Health Professions Recognition Award for making outstanding healthcare contributions to communities. Dr. Cruz is currently the Sr. Medical Director for Blue Shield of California Promise Health Plan. Promise Health Plan is Blue Shield of California’s Medi-Cal (Medicaid) health plan. He has served as the Chief Medical Officer for Molina Healthcare of California. His teams worked with medical groups, and hospital systems that care for Medicaid and dual eligible (Medicaid/Medicare) members, to improve member’s access to healthcare and elevate measures of health care quality. He developed the health plan’s first telehealth psychiatry program to address behavioral health issues. He is a board certified in Family Medicine and graduated from UC San Diego School of Medicine.

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About the Speakers & Content Experts Digna S. Forbes MD – p. 18 Digna S. Forbes, MD is Interim Dean of School of Medicine at Meharry Medical College and previous Chair of the Department of Professional & Medical Education and Senior Associate Dean for Medical Education at Meharry Medical College, Nashville, Tennessee. She is also a Staff Pathologist at Metro Nashville General Hospital. Dr. Forbes earned a Bachelor of Arts Degree from Boston University, Boston, MA, with a Major in Chemistry and a Minor in Biology and a Doctor of Medicine Degree from State University of New York at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York. Her postgraduate studies include an Internship in Department of Obstetrics & Gynecology at Sisters of Charity Hospital, Buffalo, New York; and Residency in Anatomic & Clinical Pathology, with the Graduate Medical-Dental Education Consortium of Buffalo, Buffalo, New York. Chief Residencies Anatomic and Clinical Pathology at Graduate Medical-Dental Education Consortium of Buffalo, Buffalo, New York and the Department of Pathology at New York-Presbyterian Hospital Weill-Cornell Medical Center, New York, New York. She is currently the principle investigator for the Center of Excellence grant to include but are not limited to increasing student performance, on time graduation, recruiting, mentoring, and retaining minority faculty from underrepresented groups, increasing health services research opportunities between faculty and students. Increasing our community sites for such training and institutional learning resources such as internet connectivity, electronic journals, increasing our competitive pool of qualified applicants and ensuring that cultural competency is practiced and taught as a set of skills throughout the four years of medical school education and in our residency-training program.

Renee S. Frazier MHSA, LFACHE – p. 21 Reneé S. Frazier is an experienced leader in the health care management arena with expertise in hospital operations, managed care, volunteer and community service, health promotion, strategic planning, and organizational excellence. Mrs. Frazier is a strong leader in the Memphis and Shelby County community, addressing issues of Consumer Activation, Health Policy, Environmental Barriers, Health Equity and Neighborhood Engagement. In May 2016, Mrs. Frazier retired as the first CEO of Common Table Health Alliance (CTHA) in Memphis, TN, and has remained active with the organization in an emeritus status. She had been operating a consulting practice to support strategic planning, patient-centered medical home coaching, and health equity projects. In June 2016, Mrs. Frazier started providing consulting services to Meharry to support the college-wide efforts to transform existing medical and dental curriculum, train residents and students, and transform Meharry Medical Group (MMG) into the PCMH delivery model of care. She currently serves as the project manager for the College-Wide Patient-Centered Medical Home Project, effective July, 2020.

Deliana Garcia MA – p. 19, 22 Educated at the University of Texas at Austin for both her undergraduate and graduate education, Ms. Garcia has worked at the local, state, national and international level to meet the health care needs of migrant and other underserved populations

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5th Annual Communities of Practice Conference for more than 35 years. This includes the development and delivery of more than 1000 hours of clinician and community health worker training on infectious and chronic diseases. She helped develop and coordinates a health data transfer system utilizing case managers to make available across the US and international borders the health records that assist migrants to remain in clinical care as they move for purposes of employment, family unification and safe harbor. In her role with the Migrant Clinicians Network she serves as a liaison between the governmental and nongovernmental health organizations of the US and other countries. This including collaborating with the Institute for Mexicans Abroad on the development of evaluation measures for the Ventanilla de Salud Program and other support elements. Ms. Garcia serves as a subject area expert in migration health.

Sonja Harris-Haywood MD – p. 20 Sonja Harris-Haywood, M.D., has been appointed interim associate dean of curriculum integration in the College of Medicine Office of Medical Education. In this role, Dr. Harris-Haywood oversees the development of curricular content and integration for the pre-clerkship curriculum. She will serve as module dyad leader for the HAC and CPR modules. In addition, she will also provide student success and advising for URM/URIM students in the Urban and Social Justice Pathways. Prior to this appointment, Dr. Harris-Haywood served as the associate dean of the Cleveland State University/NEOMED Partnership for Urban Health. She is an associate professor in both the department of Family and Community Medicine and Integrative Medical Sciences. Dr. Harris-Haywood earned her medical degree from New Jersey Medical School. She earned two masters degrees: one in Clinical Investigation from Case Western University and the other in Science Education from N e w York University.

James E.K. Hildreth PhD, MD – p. 18 James E.K. Hildreth, Ph.D., M.D. is the 12th president and chief executive officer of Meharry Medical College, the nation’s largest private, independent historically black academic health sciences center. Dr. Hildreth obtained a B.A. in chemistry from Harvard University and was selected as the first African-American Rhodes Scholar from Arkansas. He obtained a Ph.D. in immunology from Oxford University where his studies focused on the biology of virus-specific cytotoxic T cells. Dr. Hildreth obtained an M.D. from Johns Hopkins University School of Medicine and took a leave of absence from medical school for a postdoctoral fellowship in pharmacology at Johns Hopkins. In 1987, Dr. Hildreth joined the Johns Hopkins School of faculty as assistant professor. He was appointed as the first associate dean for graduate studies at Johns Hopkins in 1994. In 2002, Dr. Hildreth became the first African American in the 125-year history of Johns Hopkins School of Medicine to earn full professorship with tenure in basic sciences. In July 2005, Dr. Hildreth became director of the NIH-funded Center for AIDS Health Disparities Research at Meharry Medical College. In August of 2011, Dr. Hildreth became dean of the College of Biological Sciences at University of California, Davis. He was the first African-American dean in the university, which was founded in 1905. He was also appointed as a tenured professor in the Department of Cellular and Molecular Biology as well as professor in the Department of Internal Medicine in the UC Davis School of Medicine.

5th Annual Communities of Practice Conference Dr. Hildreth’s research in immunology and virology, with a focus on HIV, has resulted in more than 120 publications in top journals and 11 patents. He has received numerous NIH grants to support his research including a prestigious NIH Director’s Pioneer Award. A technology developed by Dr. Hildreth was licensed by Genentech as the basis for the FDA-approved drug Raptiva. Dr. Hildreth received numerous awards for his research, commitment to diversity in medicine, biomedical research and service to communities. His recognitions include honorary degrees, induction into the Arkansas Black Hall of Fame, the Johns Hopkins University Society of Scholars and election to the Institute of Medicine (now the National Academy of Medicine), part of the National Academy of Sciences, the most prestigious biomedical and health policy advisory group in the U.S. Dr. Hildreth has led Meharry’s effort to support the city of Nashville’s response to the COVID-19 pandemic. He serves on the city’s COVID-19 taskforce and Meharry manages all of the city’s COVID-19 test centers, performing as many as 18,000 tests per week. Meharry is also doing mobile COVID-19 mobile testing at local churches. Dr. Hildreth led the effort to establish Meharry as a COVID-19 vaccine test site as part of Operation Warp Speed. He is also leading clinical research on a promising therapeutic for moderate to severe cases of COVID-19. Dr. Hildreth has emerged as a trusted leader in the fight against COVID-19 and has appeared numerous times in local and national print and broadcast media. As a trusted messenger, he is leading efforts to ensure that minorities enroll in COVID-19 vaccine trials and that they accept vaccines when they are approved and available. Dr. Hildreth has been appointed to the FDA’s Vaccines and Related Products Advisory Committee that will review COVID-19 vaccine trial data and make recommendations for approval to the FDA commissioner. Dr. Hildreth has served on numerous national advisory boards including the Harvard University Board of Overseers. He currently serves on the Advisory Council to the NIH Director, the Veteran’s Administration National Academic Affiliations Council and the board of directors of the Association of Academic Health Centers. Dr. Hildreth serves on several other boards including chair of the board of the St. Jude Children’s Research Hospital Graduate School of Biomedical Sciences.

Cheryl L. Holder MD – p. 21 Dr. Cheryl L. Holder, Fellow in the American College of Physicians, has dedicated her medical career to serving underserved populations. She has served as a National Health Service Corp Scholar, Medical Director of one of Miami’s largest community health centers, and participated in NIH and CDC health advisory and programmatic review panels. Since 2009, as faculty at Herbert Wertheim College of Medicine at Florida International University, she focuses on teaching the impact of social determinants of health on health outcomes, addressing diversity in health professions through pipeline programs, increasing awareness of HIV prevention and health impact of climate change. Dr. Holder also serves in leadership roles in several other medical and climate change-focused organizations. Most recently, TED Talk selected her 2020 “The link between climate change, health and poverty”.as one of 25, Editor’s Pick.

About the Speakers & Content Experts Paul D. Juarez PhD – p. 18 Dr. Juarez is Professor and Vice Chair for Research in the Department of Family and Community Medicine and director of the Health Disparities Research Center of Excellence (HDRCOE) at Meharry Medical College. Dr. Juarez also is program director for the Tennessee Area Health Education Center, Director of Primary Care Training Research for National Center for Medical Education, Development, & Research, and program director for the college-wide patient centered medical home. Dr. Juarez and his team have developed the public health exposome as a systems science approach for assessing the impact of exposures in the natural, built, social and policy environments on personal health and population level disparities across the life course. Dr. Juarez also is the PI of an EPA STAR grant award: Using a Total Environment Framework (Built, Natural, Social Environments) to Assess Life-long Health Effects of Chemical Exposures); PI of a HIV Preexposure Prophylaxis (PrEP) Implementation Science award from NIAID; and is the PI of a sub-award for the NIEHS Pre-natal and Early Childhood Pathways to Health award (C Karr, PI).

Margareth Larose PharmD – p. 19.20 Every effort was made to obtain bio and photo for this participant prior to printing. An introduction will be made during the session.

Patricia Matthews-Juarez PhD – p. 18, 20, 23 Dr. Matthews-Juarez, is a social behavioral scientist, who participates in transdisciplinary and translational scientists who explore the role of epigenetics in chronic diseases and health disparities. She works within social networks for social change. Dr. Matthews-Juarez is contributing to a new way of thinking about how to address and eliminate health disparities from a collaborative transdisciplinary and translational approach, exploring the role of epigenetics in chronic diseases and health disparities. She has significant contributions to the development of a diverse and culturally competent primary care workforce who stay and work in rural and underserved communities across the United States.

James T. McElligott MD, MSCR – p. 21 James T. McElligott, M.D., MSCR, is the Executive Medical Director for Telehealth at MUSC and an Associate Professor in the Division of General Pediatrics at MUSC Children’s Hospital. He oversees the activities of the MUSC Center for Telehealth and is Co-Chair of the South Carolina Telehealth Alliance. Under his leadership the MUSC Center for Telehealth has been designated a National Center for Excellence and the South Carolina Telehealth Alliance received the ATA’ 2019 Presidents Award. His personal awards include the 2020 South Carolina State Champion Award for Telehealth, MUSC’s 2020 Physician of the Year Award, the 2020 MUSC Innovator Award, and the 2020 Margaret Jenkins Pediatric Teaching Award. Dr. McElligott currently serves as the Co-Chair of the Advisory Council of the South Carolina Telehealth Alliance, which received the American Telemedicine Association’s President’s Award in 2019. Dr. McElligott received his undergraduate education at the UNC Chapel Hill, earned his MD at the Wake Forest University School of Medicine and completed his pediatric residency and academic generalist fellowship at MUSC.

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About the Speakers & Content Experts Shanell L. McGoy PhD, MPH – p. 19 Dr. Shanell L. McGoy oversees, a 10 year, more than $100 million commitment to address the HIV/AIDS epidemic in the Southern United States supporting local communities and supporting evidence-based solutions to meet the needs of people living with and impacted by HIV/AIDS. Shanell has committed her career to addressing the HIV epidemic in the United States, and she deeply believes in equity for all marginalized communities. Additionally, with degrees in public health and health policy, and nearly 20 years of experience in epidemiology, prevention, planning, implementation, evaluation, diversity, inclusion and leadership, Shanell is suited to address barriers to achieving health equity. Dr. McGoy was Director of HIV/STD for the Tennessee Department of Health. She secured and directed governmental resources to support a $80 million comprehensive HIV/STD service delivery system for the residents of Tennessee. Shanell holds four degrees, including a B.A. in Comparative Women’s Studies from Spelman College; a MPH in Community Health Sciences from the University of Illinois at Chicago School of Public Health; a Ph.D. in Health Education from Southern Illinois University Carbondale; and a Post-Doctoral Health Policy Leadership Fellowship at the Satcher Health Leadership Institute, Morehouse School of Medicine.

Leandro A. Mena MD, MPH, FIDSA – p. 19, 21 Leandro Mena, MD, MPH, is a clinician-researcher and public health advocate with expertise in the prevention and clinical management of sexually transmitted diseases (STD) and the human immunodeficiency virus (HIV. He is the founding chair of the Department of Population Health Science at the University of Mississippi Medical Center John D. Bower School of Population Health and Professor of Medicine in the Division of Infectious Diseases, directs the Center for HIV/AIDS Research, Education & Policy at the Myrlie EversWilliams Institute for Elimination of Health Disparities, and serves as the STD Medical Director for the state of Mississippi. He is also the Medical Director of the Five Points Clinic (Jackson’s public STD clinic) and cofounded Open Arms Healthcare Center (first LGBT clinic in Mississippi). In recognition to his work developing a model program of culturallycompetent HIV prevention and care for Black men who have sex with men which is being replicated in other clinics of the country, he was awarded the 2016 Achievement Award by the Gay and Lesbian Medical Association (GLMA). He is board certified in infectious diseases and is a Fellow of the Infectious Disease Society of America. Dr. Mena is a research fellow with the Rural Center for STD/HIV Prevention (Indiana University). Dr. Mena’s interests include the understanding dynamics of HIV transmission in racial/ethnic, gender and sexual minorities as well as the development and provision of culturally competent quality health services to these populations.

Regina S. Offodile MD, MHPE, MMHC, CHse – p. 22 Dr. Offodile completed her medical education at Charles Drew University of Medicine and Science at UCLA School of Medicine. She went on to complete my surgical training at the Martin Luther King/Charles Drew Medical Center. During my surgical residency she completed

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5th Annual Communities of Practice Conference a year oncology research fellowship with Susan Love, MD at UCLA School of Medicine Department of Surgical Oncology. Following the completion of my surgical residency, she completed a Breast Surgical Oncology Fellowship at Stanford University. After being in private practice for 4 years she accepted a clinical and teaching position at Meharry Medical College. During her time at Meharry Medical College her interest in medical education grew and as a result I obtained a Masters in Health Professions Education. I subsequently combined my clinical background in surgical oncology with my education training and accepted a position in the Professional Medical Education Department. She is currently Interim Chair of the Department of Professional and Medical Education, Associate Professor and Chief of the Division of Clinical Skills and the Director of the Pamela C Williams Center for Simulation and Clinical Skills as well as Co-Director of the MeharryVanderbilt Alliance Inter-Professional Education Student project.

Freida H. Outlaw PhD – p. 18 Freida Hopkins Outlaw received her Baccalaureate in Nursing from Berea College, Masters in Psychiatric Nursing from Boston College and a Ph.D. from The Catholic University of America, and completed her postdoctoral study at the University of Pennsylvania. She has over forty years of experience as a clinician, researcher, educator, and policy maker in public mental health and substance abuse. She is currently the academic consultant for the SAMHSA Minority Fellowship Program at the American Nurses Association. Prior, she was an Associate Professor, Meharry Medical College and the Director of the Meharry Youth Health and Wellness Center, a health care delivery system for adolescents with a special focus on LGBTQ youth. For eight years she was the Assistant Commissioner, Tennessee Department of Mental Health and Substance Abuse Services. Dr. Outlaw was also an Associate Professor, University of Pennsylvania School of Nursing for a number of years. She has written in the areas of cultural diversity, management of aggression, seclusion and restraint, and the role of religion, spirituality and the meaning of prayer for people with cancer, the use of the Geriatric Depression Scale with older African Americans, Black women and depression, children’s mental health, mental health parity, ACES and Trauma Informed Care, and health policy.

Asa Radix MD, PhD, MPH, FACP – p. 18 Dr. Radix is the Director of Research and Education at the Callen-Lorde Community Health Center and a Clinical Associate Professor of Medicine at New York University. He trained in internal medicine and infectious diseases at the University of Connecticut and has over 20 years of experience providing primary care and hormone therapy to transgender patients. Dr Radix is co-chair of the World Professional Association of Transgender Health (WPATH) Standards of Care revision committee and also serves on the DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents.

Aramandla Ramesh PhD – p. 21, 23 Dr. Aramandla Ramesh is Environmental Toxicologist by training. He possesses 27 years of research & teaching experience in Environmental Toxicology, Public Health and Cancer Biology. He is a member of the Society of Toxicology, American Association for Cancer Research, Polycyclic Aromatic Compounds and American Society for Cellular and Computational Toxicology. He made seminal research contributions

5th Annual Communities of Practice Conference to environmentally induced diseases such as neurological disorders, infertility and cancer. His specific research interests are mechanisms of action of hydrocarbons, heavy metals, and particulate matter in laboratory animal models, cell cultures and humans. As Research Director of the National Center for Medical Education, Development and Research, Dr. Ramesh has been engaged in conducting systematic reviews, developing curriculum modules and policy briefs in regard to educational interventions in medical school curriculum, specifically focusing on vulnerable populations.

Jayne S. Reuben PhD – p. 18, 22 Dr. Jayne S. Reuben is an Instructional Associate Professor in the Department of Biomedical Sciences and Director of Instructional Effectiveness at the Texas A&M University College of Dentistry. She returned to the college after serving as a founding faculty member and Clinical Associate Professor in the Department of Biomedical Sciences at the University of South Carolina School of Medicine (USCSOMG) in Greenville, SC. Dr. Reuben currently serves as the course director for all undergraduate pharmacology courses in the DDS curriculum and for the Clinical Pharmacology course for dental residents. She earned her doctorate in Pharmaceutical Sciences with a specialization in Pharmacology and Toxicology from Florida Agricultural and Mechanical University (FAMU) College of Pharmacy and Pharmaceutical Sciences and then completed a postdoctoral fellowship at the University of Michigan in the Department of Pathology. A Past Chair of the American Society for Pharmacology and Experimental Therapeutics (ASPET) Division for Pharmacology Education, Dr. Reuben is the current ChairElect of the Physiology, Pharmacology and Therapeutics Section of the American Dental Education Association (ADEA). . A long-time diversity and student advocate, Dr. Reuben has authored articles and presentations on the recruitment and retention of underrepresented groups into health sciences careers and her research in the field of inflammation has been published in dental and medical journals. In addition, she has presented numerous continuing education and career development workshops for health science faculty and students.

Irene O.A. Sandvold DrPH, MSN, FACNM, FAAN – p. 18 Every effort was made to obtain bio and photo for this participant prior to printing. An introduction will be made during the session.

Marybeth Shinn PhD – p. 19 Marybeth Shinn is a Cornelius Vanderbilt professor at Vanderbilt University who studies how to prevent and end homelessness. Beth serves on the Research Council for the National Alliance to End Homelessness and Nashville’s Homeless Planning Council, coauthored a National Academies report on housing, health, and homelessness, and received research awards from the Society for Community Research and Action, the Society for Research on Adolescence, and the Association for Public Policy Analysis and Management.

Altha J. Stewart MD – p. 20

About the Speakers & Content Experts also serves as Chief of Social/Community Psychiatry and Director, Center for Health in Justice Involved Youth (Center) in the Department of Psychiatry where she manages community-based programs serving children impacted by trauma and mental illness and their families. Prior to joining the UTHSC College of Medicine faculty, she served as Executive Director of Memphis’ federally funded System of Care program for children with serious emotional disorders and their families. Dr. Stewart is the former Executive Director of the Detroit-Wayne County Community Mental Health Agency, one of the largest public mental health systems in the US. She served as Deputy Commissioner and later Interim Commissioner of the former New York City Department of Mental Health, and CEO/Executive Director in other large public health and mental health systems in New York and Pennsylvania, overseeing the management and development of programs for persons with mental illness, substance use disorders, and justice system involvement. Dr. Stewart received her medical degree from Temple University Medical School, completing her psychiatric residency at what is now Drexel University. In 2017, Dr. Stewart was elected the 145th President of the American Psychiatric Association, the first African American ever elected to this position in the 175-year history of the organization. She is also past president of the Black Psychiatrists of America, the Association of Women Psychiatrists and the American Psychiatric Foundation. She has received numerous awards and honors including honorary degrees, visiting professorships and honorary membership in the South African Society of Psychiatrists.

Keaton S. Thorum BS, BA – p. 19, 20 Keaton is a sophomore undergraduate student at Virginia Commonwealth University studying Chemistry and Hispanic Studies. Keaton is a part of the Guaranteed Admissions program for the VCU school of Pharmacy. In addition, He is the president of the VCU Triangle Club, an organization focused on Health equity, Political and social education, and socialization for LGBTQ+ individuals in the Richmond Area. He also works with Collective Corazón, a student organization made to help fight health inequities seen within the Latinx Community within the Greater Richmond Area. Due to his passion in public health work, Keaton plans on obtaining his M.P.H. in addition to his Pharm.D.

Febe I. Wallace MD – p. 21 Febe Wallace, MD, FAAP, received her medical degree from Duke University and completed a combined internal medicine and pediatric residency at North Carolina Memorial Hospital. For 35 years, she has provided primary care services in a variety of practice settings, both academic and community based settings. She has provided primary care services for Cherokee Health Systems for 14 years, serving as Director of Primary Care Services for the past 6 years. As part of the mission of Cherokee Health Systems, one priority has been to lead the expansion of clinical services to marginalized populations via virtual platforms.

Dr. Altha J. Stewart is Senior Associate Dean for Community Health Engagement and Associate Professor in Psychiatry at University of Tennessee Health Science Center in Memphis, Tennessee. She

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About the Speakers & Content Experts G. Robert (Bobby) Watts MPH, MS, CPH – p. 20, 22 Bobby Watts is the CEO of the National Health Care for the Homeless Council, which supports 300 Health Care for the Homeless Federally Qualified Health Center (FQHC) programs and 100 Medical Respite programs with training, technical assistance, policy analysis and advocacy to end homelessness. Bobby has over 25 years’ experience in administration, direct service, and implementation of homeless health services. He served as the executive director of New York City’s Care for the Homeless from 20052017.

Suzanne L. Wenzel PhD – p. 19 Suzanne L. Wenzel, PhD, is the Richard and Ann Thor Professor in Urban Social Development and former interim dean in the Dworak-Peck School of Social Work, University of Southern California. With National Institutes of Health sponsorship, she has conducted interdisciplinary research for more than two decades to understand and address behavioral health, social, community, and service needs among persons who are marginalized in society, particularly individuals experiencing homelessness. She has served on study sections for NIH and other national and international health science and service organizations, and consulted for the White House Office of National AIDS Policy during the Obama administration.

Stephanie White MD, MS – p. 19 Stephanie White, MD is Associate Professor in the Department of Pediatrics and Associate Dean for Diversity and Inclusion in the UK College of Medicine. Having received training in implementing best practices to support diversity, equity, and inclusion in academic medicine through the Association of American Medical College’s (AAMC) Heath Executive Diversity and Inclusion Certificate program, Dr. White brings expertise in using this lens to address negative contributors to academic culture, enhance faculty development, and ensure policies and procedures are in place to support change and ultimately provide care for our most vulnerable populations.

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5th Annual Communities of Practice Conference Eboni Winford PhD, MPH – p. 19 Eboni Winford, Ph.D., MPH, is the Director of Research and Health Equity and a licensed psychologist at Cherokee Health Systems in Knoxville, TN. Dr. Winford is the clinical lead for CHS’s consultation and training program, which provides individualized on-site training to other primary care organizations as they seek to integrate their practices. She oversees research initiatives including those funded by the HRSA, the TN Department of Health, and the NIH. She holds membership roles in organizations such as the Collaborative Family Healthcare Association, the American Public Health Association, and the American Psychological Association. Dr. Winford earned her doctoral degree in Clinical Health Psychology from the University of North Carolina at Charlotte and a Master of Public Health from the University of North Carolina at Chapel Hill. She is a proud life member of Zeta Phi Beta Sorority, Incorporated.

NOTES

Meharry Medical College Department of Family and Community Medicine National Center for Medical Education Development and Research 1005 Dr. D.B. Todd Jr. BLVD, Nashville, TN 37208 www.NCMEDR.org

The Primary Care Training and Enhancement Academic Units (AU) project is supported in part through a cooperative agreement (UH1HP30348) with the US Department of Health and Human Services (DHHS)/Health Resources and Services Administration (HRSA) and Department of Family and Community Medicine, School of Medicine, Meharry Medical College. This information, content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by DHHS, HRSA or the US Government.

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