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The National Center for Medical Education Development and Research

The 3rd Annual Communities of Practice Conference

Transforming the Culture of Medical Education May 29â€“30, 2019 Nashville Marriott at Vanderbilt in Nashville, TN

What is a Community of Practice?

3rd 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 membersâ€™ 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).

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 author 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.

http://NCMEDR.org

Table of Contents

4 12 14 16 24 41 55 64 72 75 80 86 91

NCMEDR History and Years 1–3 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.

Proposed Year 4 Research Projects

Review our proposed year 4 projects and prepare for our presentations and discussion sessions.

Conference Posters

Review the Year 3 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.

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

Faculty, Staff, & Community Partners

We extend our appreciation to all conference participants at the 2019 Conference.

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NCMEDR History

3rd 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.

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3rd 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 medi-cal students to address implicit physician bias towards LGBTQ persons, persons ex-periencing 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.

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NCMEDR History

3rd 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, Ef-fects 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 Dispari-ties Conference. 4/19/2018. »» EDUCATIONAL INTERVENTIONS FOR ASSESSING ADVERSE CHILDHOOD EXPERIENCE. Poster presented at 11th Xavier Health Disparities Conference. 4/19/2018.

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3rd Annual Communities of Practice Conference

NCMEDR History

Our third year topics were: »» 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 Vulnera-ble 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 Confer-ence. 4/19/2018. »» Patient/provider survey of how opioid misuse is being addressed in primary care is under discussion.

http://NCMEDR.org

School of Medicine National Center for Medical Education, Development and Research

Dear Content Experts and Thought Leaders: The National Center for Medical Education Development and Research (NCMEDR), with its 3rd Annual Communities of Practice conference, contributes to the transformative best practice strategies of evidencebased interventions for vulnerable populations. These populations include LGBTQ, person experiencing homelessness, and migrant farm workers; and this convening brings together national experts and stakeholders to examine faculty and medical education and curriculum strategies to inform primary care training and provide resources to providers and trainees. These experts and stakeholders will assist the center in making recommendations about medical education curriculum transformation and innovation. Meharry Medical College welcomes you to this significant convening. We appreciate your commitment and contributions over the next two days. Your presence here aids in strengthening the institutionâ€™s commitment to transform primary care training in medical education and clinical practice in Tennessee and within the United States. It is a responsibility that MMC is primed to exemplary patient care, and compassionate community outreach. Thank you for participating in helping us continue and grow our mission. The National Center for Medical Education Development and Research is unique in its effort to conduct medical education research that will identify and impact curriculum in medical education focusing on LGBTQ, Persons Experiencing Homelessness and Migrant Farm Workers. The research of the Center will inform medical school curriculum about the extent and impact of our training of medical students, especially in the area of health equity. Thank you for joining us. We appreciate your time and commitment. Sincerely,

Veronica Mallet, M.D., MMM Senior Vice President for Health Affairs Dean, School of Medicine

National Center for Medical Education, Development and Research

Welcome Content Experts and Thought Leaders: Over the last year, we have worked very hard to complete medical education research in the areas of opioids misuse and sexual violence. These are two powerful topics that have raised many questions about the role of health care teams, physicians in the patient-centered medical home, access to care, quality of care and services, as well as the cost of services. These topics have also inspired our work around the use of the electronic health record and valued-based pricing of health services. The staff of the National Center on Medical Education Development and Research, led by Dr. Paul D. Juarez, is committed to excellence. We, as a Center, continue to enlist your assistance in translating and interpreting our work for medical schools in the United States and Canada as well as the general public. We are pleased that you are providing the Center with expert advice and reviewing the products produced, including examining the structure and underlying assumptions of our surveys. These surveys are geared toward answering the underlying question: Is medical school curriculum training medical students to provide patient-centered care to vulnerable populations who are lesbian, gay, bisexual, transgender, and questioning, persons experiencing homelessness and migrant farmworkers. Thank you for taking the time to join us. We look forward to a wonderful and challenging two days. Best,

Pat Matthews-Juarez, PhD Project Director Professor Department of Family and Community Medicine Senior Vice President Faculty Affairs and Development Office of the President

National Center for Medical Education, Development and Research

Dear Colleagues, I would like to welcome and thank each of you for your participation in the 2019 NCMEDR Community of Practice (CoP) meeting. The overall goal of the CoP is to lead efforts to shape the training of medical students to better address the health needs of vulnerable populations. The CoP is comprised of persons with lived experience and content experts who are knowledgeable about the health needs of three vulnerable populations: LGBTq, persons experiencing homelessness, and migrant farmworkers; invited experts who will help us develop a research plan for addressing year four research topics; and medical education faculty who can help guide recommendations for transforming medical education curriculum. Your combined wisdom, experiences, and insights are vital to the process of taking all of that information and translating it into medical education and practice transformation recommendations. We are truly grateful that you have elected to take the time to participate with us in this critical process. At this year’s meeting we will showcase the outcomes and achievements of the Center over the past year, get your input and recommendations for our year four research projects, identify strategies for translating research results into medical education curriculum, and identify and pursue dissemination strategies to reach multiple audiences in order to achieve maximum impact. We look forward to your participation in this process as we move forward together in shaping the education of the next generation of physicians so that they are better prepared to address the needs of vulnerable populations. The processes and outcomes we identify at this year’s conference will guide the efforts of the NCMEDR over the next year. Again, thank you for agreeing to participate, now let’s get to work.

Paul D. Juarez, PhD Program Director NCMEDR

National Center for Medical Education, Development and Research

Dear Colleagues: The National Center for Medical Education Development and Research welcomes each of you to the 3rd Annual Communities of Practice (CoP) Conference. Our Center has an exciting and robust agenda this year. You will have hands on opportunities to connect with CoP members on site and via social media. In addition to our CoP webinars, conference, and monthly meetings, you will have an opportunity to engage with the Center as we work collaboratively to transform medical education and clinical practice, to meet the needs of vulnerable populations. We recently launched our inaugural faculty exchange CoP, established MOUs and relationships with national partners and expanded our CoP. As a group of content experts, thought leaders, academics, researchers, policy analysts and community leaders your combined expertise gives us a unique and multifaceted perspective that will ensure the Center is responding to current educational needs of medical students. The Communities of Practice are always seeking new members who will add value to our shared goals. Now that we have your voice, let us consider what voices are missing and expand our CoP in the years to come. We look forward to hearing from you. This is going to be a great conference! Sincerely,

Katherine Y. Brown

Katherine Y. Brown, EdD, MSEd, OTR/L Director, Communities of Practice Assistant Professor Department of Family and Community Medicine

About NCMEDR

3rd 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

3rd Annual Communities of Practice Conference

About NCMEDR

Our proposed Year 4 Research Areas, which will be prioritized with input from the CoP, include the following four topics: »» Immunization disparities among vulnerable populations. LGBTQ, persons experiencing homelessness, and 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 and uptake of vaccination for prevention. The unique conditions and circumstances encountered by these vulnerable populations can serve as obstacles to completing the recommended childhood and adult vaccination schedules, exposing them, and people they come into contact with increased risk for contracting infectious, yet preventable diseases. The purpose of this study is to identify whether and/or how medical students are being taught to recognize and address the challenges encountered by vulnerable populations in completing the schedule of childhood and adult immunizations. »» Mental health needs of vulnerable populations. 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. »» Gender reassignment among persons who are transgender. A gap exists between the needs of transgender patients and the didactic and clinical transgender education medical students receive. Perceived importance of gender-confirming surgical training varies among medical students by specialization interest, sex and geography. While medical school education has focused mainly on introducing students to transgender health, a number of medical residency specialty and sub-specialty programs, including OB/GYN, Urology, and Surgery have identified the need for residents to receive training in gender reassignment. »» Occupational exposures among migrant farm workers. The exposure of migrant and seasonal farmworkers and their families to agricultural and residential pesticides is a continuing public health concern. This research project will assess the extent to which medical schools prepare students to address the needs of vulnerable populations experiencing occupation-related health issues in primary care settings. It will employ multiple methods to assess current medical school educational practice, identify evidence-based best practices, and 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.

http://NCMEDR.org

Program at a Glance

3rd Annual Communities of Practice Conference

DAY 1: WEDNESDAY, MAY 29, 2019

10:00 AM – 4:00 PM Parthenon Prefunction

Registration

11:30 AM – 12:00 PM Parthenon Prefunction

Lunch

12:00 PM – 12:20 PM Parthenon C

Opening Session

12:25 PM – 1:30 PM Parthenon C

General Session I

1:30 PM – 2:05 PM Parthenon C

General Session II

2:10 PM – 3:55 PM Parthenon C, D, & E

Working Group Session 1

4:00 PM – 4:30 PM Parthenon C

Summary of Sessions with Recommendations for Transforming Medical School Curriculum and Clinical Practice

4:30 PM – 5:30 PM Crescent Room

Networking Reception

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Greetings & Overview

Sexual Violence and Opioid Misuse among Vulnerable Populations (LGBTQ, Persons Experiencing Homelessness, and Migrant Farm Workers)

Best Practices: The Role of Medical Schools in Addressing Opioid Misuse among Vulnerable Populations (LGBTQ, Persons Experiencing Homelessness, and Migrant Farm Workers)

Transforming Medical School Curriculum and Clinical Practice

3rd Annual Communities of Practice Conference

Program at a Glance

DAY 2: THURSDAY, MAY 30, 2019 7:30 AM – 1:00 PM Parthenon Prefunction

Registration

8:00 AM – 8:30 AM Parthenon Prefunction

Full Breakfast

8:00 AM – 9:30 AM Parthenon C

Social Media Residency

9:30 AM – 9:35 AM Parthenon C

Overview Session

9:35 AM – 10:25 AM Parthenon C

General Session III

10:30 AM – 11:25 AM Parthenon C, D, & E

Working Group Session 2

11:30 AM – 12:00 PM Parthenon C

Engaging Communities of Practice in Dissemination and Data Sharing Activities

12:00 PM – 12:30 PM Parthenon Prefunction

Lunch

Using Social Media for Training Health Professionals Working with Vulnerable Populations

Day 1 Recap

Year 4 Research Areas

Building Consensus in Medical School Curriculum Transformation

12:30 PM – 1:00 PM Parthenon C

Reporting Session

1:00 PM – 1:20 PM Parthenon C

Bioethics: Ethical Considerations for Transforming Curriculum and Clinical Practice

1:20 PM – 1:30 PM Parthenon C

Communities of Practice Lessons Learned & Pathways Forward

Year 4 Research Projects

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Program Agenda

3rd Annual Communities of Practice Conference

OPENING SESSION

Greetings & Overview Wednesday, May 29, 2019 • 12:00 PM – 12:20 PM Welcome

Patricia Matthews-Juarez, PhD Meharry Medical College

Greetings

The Honorable Brenda Gilmore Senator, D-19th District, State of Tennessee

Greetings

Millard D. Collins, MD Meharry Medical College

Greetings & Overview of Day 1 and Introduction of Thought Leaders & Content Experts to Explore Year 3 Topics Introduction

Paul D. Juarez, PhD Meharry Medical College

Katherine Y. Brown, EdD, OTR/L Meharry Medical College

GENERAL SESSION I

Sexual Violence and Opioid Misuse among Vulnerable Populations (LGBTQ, Persons Experiencing Homelessness, and Migrant Farm Workers) Wednesday, May 29, 2019 • 12:25 PM – 1:30 PM

Facilitator Content Expert LGBTQ Content Expert Persons Experiencing Homelessness Content Expert Migrant Farm Workers The Role of the State of Tennessee in Shaping the Training of Health Professionals in Addressing the Opioid Epidemic in Tennessee Discussion, Questions & Answers

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Renee S. Frazier, MHSA, FACHE Retired CEO, Commontable Health Alliance Lawrence Bryant, PhD, MPH, BSW, RRT Kennesaw State University G. Robert Watts, MPH, MS, CPH National Health Care for the Homeless Council Angela W. Walter, PhD, MPH, MSW University of Massachusetts Lowell Wesley Geminn, PharmD Tennessee Department of Mental Health and Substance Abuse Services

3rd Annual Communities of Practice Conference

Program Agenda

GENERAL SESSION II

Best Practices: The Role of Medical Schools in Addressing Opioid Misuse among Vulnerable Populations (LGBT, Persons Experiencing Homelessness, and Migrant Farm Workers) Wednesday, May 29, 2019 • 1:30 PM – 2:05 PM Introduction of Keynote Speaker Keynote Speaker Addressing Opioid Misuse through Multidisciplinary Research

Paul D. Juarez, PhD Meharry Medical College Robert DiPaola, MD University of Kentucky

Questions & Answers Introduction of Concurrent Working Groups

Katherine Y. Brown, EdD, OTR/L Meharry Medical College

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Program Agenda

3rd Annual Communities of Practice Conference

WORKING GROUP SESSION 1A

Teaching Medical Students to Address Sexual Violence among LGBTQ Patients Wednesday, May 29, 2019 • 2:10 PM – 3:55 PM Moderator / NCMEDR Consultant Content Expert

Leandro A. Mena, MD, MPH University of Mississippi Medical Center Angelica G. Fugerson, DrPH, MPH Morehouse School of Medicine

WORKING GROUP SESSION 1B

Teaching Medical Students to Address Sexual Violence among Persons Experiencing Homelessness Wednesday, May 29, 2019 • 2:10 PM – 3:55 PM Moderator / NCMEDR Consultant Content Expert

Marybeth Shinn, PhD Vanderbilt University Suzanne L. Wenzel, PhD University of Southern California

WORKING GROUP SESSION 1C

Teaching Medical Students to Address Sexual Violence among Migrant Farm Workers Wednesday, May 29, 2019 • 2:10 PM – 3:55 PM Moderator / NCMEDR Consultant Content Expert

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Thomas A. Arcury, PhD Wake Forest School of Medicine Jillian Hopewell, MPA, MA Migrant Clinicians Network

3rd Annual Communities of Practice Conference

Program Agenda

Summary of Sessions with Recommendations for Transforming Medical School Curriculum and Clinical Practice Wednesday, May 29, 2019 • 4:00 PM – 4:30 PM Facilitator

Paul D. Juarez, PhD Meharry Medical College

Networking Reception Wednesday, May 29, 2019 • 4:30 PM – 5:30 PM

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Program Agenda

3rd Annual Communities of Practice Conference

SOCIAL MEDIA RESIDENCY

Using Social Media for Training Health Professionals Working with Vulnerable Populations Thursday, May 30, 2019 • 8:00 AM – 9:30 AM Speaker

Lee A. Aase Mayo Clinic

Speaker

Katherine Y. Brown, EdD, OTR/L Meharry Medical College

Questions & Answers

OVERVIEW SESSION

Day 1 Recap Thursday, May 30, 2019 • 9:30 AM – 9:35 AM Facilitator

Paul D. Juarez, PhD Meharry Medical College

GENERAL SESSION III

Year 4 Research Topic Areas Thursday, May 30, 2019 • 9:35 AM – 10:25 AM Instructions

Paul D. Juarez, PhD Meharry Medical College

Prioritizing Year 4 Research Topics Immunization Disparities Mental Health Needs Gender Reassignment Occupational Exposures among Migrant Farm Workers Reporting Out Introduction of Concurrent Working Groups

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Katherine Y. Brown, EdD, OTR/L Meharry Medical College

Program Agenda

3rd Annual Communities of Practice Conference WORKING GROUP SESSION 2

Building Consensus in Medical School Curriculum Transformation Thursday, May 30, 2019 • 10:30 AM – 11:25 AM Research Projects, Policy Briefs, & Dissemination LGBTQ Persons Experiencing Homelessness Migrant Farm Workers

Asa Radix, MD, MPH Callen-Lorde Community Health Center Marvin L. Crawford, MD, MDiv, FACP Morehouse School of Medicine Suzanne L. Wenzel, PhD University of Southern California Renay Scales, PhD University of Kentucky Angela W. Walter, PhD, MPH, MSW University of Massachusetts Lowell Freida H. Outlaw, PhD, RN, APRN, FAAN American Nurses Association

Engaging Communities of Practice in Dissemination and Data Sharing Activities Thursday, May 30, 2019 • 11:30 AM – 12:00 PM This session incorporates the current status of our CoP and dissemination outcomes.

Speaker

Katherine Y. Brown, EdD, OTR/L Meharry Medical College

Speaker

Wansoo Im, PhD Meharry Medical College

Questions & Answers

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Program Agenda

3rd Annual Communities of Practice Conference

REPORTING SESSION

Year 4 Research Projects Thursday, May 30, 2019 • 12:30 PM – 1:00 PM LGBTQ Persons Experiencing Homelessness Migrant Farm Workers

Bioethics: Ethical Considerations for Transforming Curriculum and Clinical Practice Thursday, May 30, 2019 • 1:00 PM – 1:20 PM Speaker

Reuben C. Warren, DDS, MPH, DrPH, MDiv Tuskegee University

Questions & Answers

Communities of Practice Lessons Learned and Pathways Forward Thursday, May 30, 2019 • 1:20 PM – 1:30 PM Speaker

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Patricia Matthews-Juarez, PhD Meharry Medical College

3rd Annual Communities of Practice Conference

Program Agenda

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Year 1 Research Projects

3rd Annual Communities of Practice Conference

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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3rd Annual Communities of Practice Conference

Year 1 Research Projects

LIMITATIONS Findings of the systematic review were limited as none addressed the impact of implicit bias training on changing studentsâ€™ 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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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 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.

3rd Annual Communities of Practice Conference 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. 28. Sabin JA, Riskind RG, Nosek BA. Health Care Providersâ€™ 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

Year 1 Research Projects 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 studentsâ€™ 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

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Year 1 Research Projects 43. Strong KL, Folse VN. Assessing undergraduate nursing studentsâ€™ 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 nursesâ€™ 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

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3rd Annual Communities of Practice Conference 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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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 PrEPâ€™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 physiciansâ€™ 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 non-judgmentally. 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 1: 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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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.

3rd 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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3rd 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), physicianâ€™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 Development 38. These competencies include the need for understanding that implicit LGBTQ-related 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.

3rd 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 Research Projects

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 LGBT, 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):716-724. 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 4alcohol 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 barriersâ€”exacerbated by their status as migrant and as farmworkers, and often as unauthorized workersâ€”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 studentsâ€™ 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 studentsâ€™ 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.

3rd 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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3rd 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 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 â€“ 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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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

3rd Annual Communities of Practice Conference

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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 â€œmajor problem.â€? 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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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 (TO BE COMPLETED)

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

3rd Annual Communities of Practice Conference

Year 3 Research Projects

YEAR 3 POLICY BRIEF (TO BE COMPLETED)

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

BACKGROUND 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 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 victimized7 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. 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.

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. 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, graduate medical education, medical school curriculum medical education, and curriculum. To be included in this systematic review, a study had to: 1) focus on undergraduate and graduate medical education, 2) be written in English; 3) be undertaken in a US medical schools or residency training programs 4) be published prior to January 2019. We did not include articles conducted with other health professions (i.e. dental, nursing, social work, etc) or continuing education of health care providers or were letters to the editor.

RESULTS An initial total of 1,715 articles were initially identified from the eight databases. PubMed search results yielded 650 articles, 40 were identified from OVID, 51 from ERIC, 250 from SCOPUS, 91 from Web of Science, 90 from CINAHL, 478 from PsychInfo, and 65 from Google Scholar. This number was reduced to 1,596 after duplicates were removed and further reduced to 1,586 after books and book sections were taken out. An additional 1,572 articles were removed after a review of titles and abstracts, leaving 14 for full text review.

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After a full text review was completed only 5 articles met the inclusion criteria. One survey was completed by medical students and another by third-year family medicine and pediatrics residents and fourth-year residents in OB/GYN) about knowledge, attitudes, and experiences regarding sexual abuse while one made recommendations of the need to educate medical students about sexual assault and rape Only one articles described an educational intervention (i.e., lecture) to assess changes in knowledge and attitudes of medical students towards the need for education on sexual assault/rape. This review did not include continuing education of practicing physicians and other health care providers or include articles that had a broad focus on related topics such as child abuse, interpersonal violence, sexual education, and sexual history taking.

CONCLUSIONS One article implored the need to include sexual violence as part of the educational experience of medical students while two articles used a research design to assess the effectiveness of an educational intervention. One educational intervention consisted of a single lecture on sexual violence while the other used a pre/post design to assess the impact of a simulation based an 8-hour, sexual assault response course, but was limited to 12 emergency medicine residents. The lack of articles identified that advocated or described efforts to teach medical students or residents how to conduct screening for a history of sexual violence is alarming. No articles were identified that addressed the specific needs of vulnerable populations, including those who are LGBTQ, persons experiencing homelessness or migrant farm workers.

RECOMMENDATIONS Sexual violence is a common experience in the lives of both men and women and has been found to have lasting impact on health and mental health of victims. While no one is immune—It crosses all socioeconomic, racial, gender, and cultural boundaries, some populations are at heightened risk—including LGBTQ persons, persons experiencing homelessness, and migrant farm workers. There is a clear need to update the education and training of medical students and residents about sexual violence and to conduct research on the effectiveness and impact of educational interventions.

ANNOTATED REFERENCES Ambuel B, Butler B, Hamburger LK, Lawrence S, Guse CE (2003). Female and Male Medical Students’ Exposure to Violence: Impact on Well Being and Perceived Capacity to Help Battered Women. Journal of Comparative Family Studies, 34: 113-135. Physicians play a key part in society’s response to violence against women. Their professional role affords them the opportunity to talk privately with women, identify victims of abuse, and offer support. However physicians’ own history of victimization may undermine their ability to assist battered women. We used an anonymous, self-report survey to describe the violence history of students enrolled at a medical school, and explore the relationship between students’ violence history, current well-being, help seeking, and expected future impact on education and clinical care of patients. Valid surveys were returned by 472 of 810 students. 53% reported experiencing one or more forms of severe violence (30% reported severe child physical abuse; 6% child sexual abuse by a family member; 13% child sexual abuse by a non-family member; 22% severe partner violence; 7% adult sexual assault). Participants with a history of severe violence were more likely to report feeling downhearted and blue. Some participants with a severe violence history reported that these experiences would interfere with their ability to feel good about themselves (32%), develop relationships (38%), work effectively (11%), participate in courses dealing with violence and abuse (15%), and assist patients with experiences similar to their own (18%). Women students experienced more severe physical and sexual violence, and expected more future difficulties in their personal and work life. Results are discussed in the context of the history of gender discrimination in medicine, and the need for new methods for training physicians to identify and assist victims of partner violence. https://www.researchgate.net/profile/Bruce_Ambuel/publication/237185000_Female_and_Male_Medical_Students’_Exposure_to_Violence_Impact_on_ Well_Being_and_Perceived_Capacity_to_Help_Battered_Women-/links/00b49536a5bf36f10d000000/Female-and-Male-Medical-Students-Exposure-toViolence-Impact-on-Well-Being-and-Perceived-Capacity-to-Help-Battered-Women.pdf

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Year 3 Research Projects

Auten JD, Ross EM, French MA, Li IZ, Robinson L, Brown N, et al. Low-Fidelity Hybrid Sexual Assault Simulation Trainingâ€™s Effect on the Comfort and Competency of Resident Physicians. The Journal of Emergency Medicine. 2015;48(3):344-50. doi: https://doi.org/10.1016/j. jemermed.2014.09.032 Kennedy K (2014). The case in favor of educating medical students about sexual violence, Medical Teacher, 36:3, 267-268. Medical students should be educated about sexual assault and rape. There is a strong argument in favour of such an educational intervention in all medical schools. Sexual violence is a highly prevalent medical condition that has very significant personal health consequences. Sexual violence is an issue that is frequently misunderstood by the general public and by healthcare professionals. Routine inclusion of this topic on undergraduate medical curricula should improve care provided to victims of sexual violence. https://www.ncbi.nlm.nih.gov/pubmed/24559306 (abstract only)

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. doi: 10.1080/10401330903446321. Olsen, M. E., & Kalbfleisch, J. H. (2001). Sexual abuse knowledge base among residents in family practice, obstetrics/gynecology, and pediatrics. J Pediatr Adolesc Gynecol, 14(2), 89-94. Abstract: STUDY OBJECTIVE: To investigate resident physician knowledge about sexual abuse prevalence and understanding about potential perpetrators. DESIGN: Questionnaires were mailed to program directors in family practice, obstetrics and gynecology, and pediatric residency programs. PARTICIPANTS: The questionnaires were distributed to senior residents in their final months prior to graduation. INTERVENTIONS: Residents were asked to fill out the questionnaire anonymously and return it to our institution in the prepaid envelope provided. MAIN OUTCOME MEASURES: Demographic characteristics and knowledge of sexual abuse prevalence and perpetrator characteristics were assessed. Chi-square contingency table analysis was used to compare responses of the three specialties. RESULTS: The overwhelming majority (98.8%) of residents correctly identified a family member as the individual most likely to sexually abuse a child. Approximately half of the residents knew the correct prevalence of sexual abuse among females and among males. There was a weak understanding of the potential youthfulness of juvenile offenders. CONCLUSION: We believe that resident understanding of sexual abuse prevalence and about the youthfulness of juvenile offenders can be improved in all three specialties. https://www.ncbi.nlm.nih.gov/pubmed/11479107

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Year 4 Research Projects

3rd Annual Communities of Practice Conference

PROPOSED YEAR 4 RESEARCH TOPIC (SYSTEMATIC REVIEWS AND POLICY BRIEFS TO BE DEVELOPED)

Childhood and Adult Immunization Disparities 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 Vaccines reduce a persons risk of infection by working with their body’s natural defenses to help them safely develop immunity to disease. Vaccines help develop immunity by imitating an infection, but this “imitation” infection does not cause illness. Instead it causes the immune system to develop the same response as it does to a real infection so the body can recognize and fight the vaccine-preventable disease in the future. The Advisory Committee on Immunization Practices (ACIP) is a group of medical and public health experts that develops recommendations on how to use vaccines to control diseases in the United States. The 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. For children birth to 6 years of age, the vaccine schedule includes chickenpox, diphtheria, flu, hepatitis A, Hepatitis B, Hib, measles, mumps, polio, pneumococcal, rotavirus, rubella, tetanus, and whopping cough. For children and teens, 7 through 18 years of age, the CDC recommends vaccines for flu, HPV, meningococcal, and TDAP. For adults 19-64, the National Center for Immunization and Respiratory Diseases recommends a schedule of vaccines for influenza (annually), Tdap, MMR, VAR, RZV, HPV, PCV13, PPSV23, HepA, HepB, MenACWY, MenB, and Hib For persons over 65, the CDC also recommends vaccines for influenza, MMR, RZV, PCV13, HPV, PCV13, and PPSV23. Millions of Americans experience difficulties obtaining culturally competent, primary care due to cost, social and economic tradeoffs, and lack of accessibility. Unique circumstances and exposures encountered by persons who are lesbian, gay, bisexual and transgender (LGBT), 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. Disparities in health care access and quality create barriers for vulnerable populations that increase risk for adverse health outcomes.

PURPOSE Homeless and LGBT persons and 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 and uptake of vaccination for prevention. The unique conditions and circumstances encountered by these vulnerable populations can serve as obstacles to completing the recommended childhood and adult vaccination schedules, exposing them, and people they come into contact with increased risk for contracting infectious, yet preventable diseases. The purpose of this study is to identify whether and/or how medical students are being taught to recognize and address the challenges encountered by vulnerable populations in completing the schedule of childhood and adult immunizations.

METHODS We will conduct a systematic review literature using the PRISMA 2009 Checklist to identify how medical students and health care providers are being taught to recognize and respond to the unique immunization needs of LGBTQ and homeless and migrant farm workers. The purpose of this review is to identify how medical schools are training students to address the immunization needs of vulnerable populations. 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 their immunization needs.

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Year 4 Research Projects

REFERENCES 1. 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. 2. 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 3. 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 4. 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 5. 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. 6. 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:10.1179/2047772412Z.00000000086 7. 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 8. 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 9. 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), 880884. doi:10.3382/ps.2008-00335 10. Hurley, L. P., Bridges, C. B., Harpaz, R., Allison, M. A., Oâ€™Leary, S. T., Crane, L. A., . . . Kempe, A. (2014). U.S. Physiciansâ€™ Perspective of Adult Vaccine Delivery. Annals of Internal Medicine, 160(3), 161-161. doi:10.7326/M13-2332 11. 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 12. 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:10.7326/0003-4819-152-9201005040-00005 13. 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 14. 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 15. 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 16. Kemsley, M., & Riegle, E. A. (2004). A Community-campus Partnership: Influenza Prevention Campaign. Nurse Educator, 29(3), 126-129. 17. 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. 18. 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 19. 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. 20. 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 21. 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

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Year 4 Research Projects

3rd Annual Communities of Practice Conference

PROPOSED YEAR 4 RESEARCH TOPIC (SYSTEMATIC REVIEWS AND POLICY BRIEFS TO BE DEVELOPED)

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 is currently 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.

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?

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 to a graduate medical education audience on how medical schools are addressing mental health care for vulnerable populations.

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Year 4 Research Projects

REFERENCES 1. Talen, M. R., Baumer, J. G., & Mann, M. M. (2013). Screening measures in integrated behav-ioral 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 victim-ization—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). Non-disclosure 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 Orthopsy-chiatry, 69(4), 438-447. 14. Irestig, R., Burström, K., Wessel, M., & Lynöe, N. (2010). How are homeless people treated in the healthcare system and other societal institutions? Study of their experiences and trust. Scan-dinavian 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). Eco-nomic 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 Caroli-na. Journal of Rural Mental Health, 42(2), 89. 18. Drewniak, D., Krones, T., & Wild, V. (2017). Do attitudes and behavior of health care profession-als exacerbate health care disparities among immigrant and ethnic minority groups? An integrative literature review. International journal of nursing studies, 70, 89-98.

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Year 4 Research Projects

3rd Annual Communities of Practice Conference

PROPOSED YEAR 4 RESEARCH TOPIC (SYSTEMATIC REVIEWS AND POLICY BRIEFS TO BE DEVELOPED)

Systematic Review: Gender Reassignment 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., Katherine Brown, EdD, and Patricia Mathews-Juarez, Ph.D.

BACKGROUND A gap exists between the needs of transgender patients and the didactic and clinical transgender education medical students receive. Perceived importance of gender-confirming surgical training varies among medical students by specialization interest, sex and geography. While medical school education has focused mainly on introducing students to transgender health, a number of medical residency specialty and sub-specialty programs, including OB/GYN, Urology, and Surgery have identified the need for residents to receive training in gender reassignment.

METHODS We will conduct a systematic review literature using the PRISMA 2009 Checklist to identify how medical students and health care providers are being taught to recognize and respond to the unique immunization needs of LGBTQ and homeless and migrant farm workers. The purpose of this review is to identify how medical schools are training students to address the medical need for gender reassignment among transgender patients. In addition, we will work with our Community of Practice to identify strategies to teach medical students to better address the health care needs of transgender patients.

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Year 4 Research Projects

REFERENCES Chang OH, Haviland MJ, Von Bargen E, Gomez-Carrion Y, Hacker MR, Li J. Female pelvic medicine and reconstructive surgery fellows’ exposure to transgender health care. American Journal of Obstetrics and Gynecology. 2018;219(6):625-6. doi: https://doi.org/10.1016/j. ajog.2018.09.012. 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):128690. doi: 10.1210/jc.2016-3007. Dubin SN, Nolan IT, Streed CG, Jr., Greene RE, Radix AE, Morrison SD. Transgender health care: improving medical students’ and residents’ training and awareness. Advances in medical education and practice. 2018;9:377-91. doi: 10.2147/AMEP.S147183. PubMed PMID: 29849472. Dy GW, Osbun NC, Morrison SD, Grant DW, Merguerian PA. Exposure to and Attitudes Regarding Transgender Education Among Urology Residents. The Journal of Sexual Medicine. 2016;13(10):1466-72. doi: https://doi.org/10.1016/j.jsxm.2016.07.017.

Korpaisarn S, Safer JD. Gaps in transgender medical education among healthcare providers: A major barrier to care for transgender persons. Reviews in Endocrine and Metabolic Disorders. 2018;19(3):271-5. doi: 10.1007/s11154-018-9452-5. 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. doi: 10.4158/ EP171758.OR. Morrison SD, Chong HJ, Dy GW, Grant DW, Wilson SC, Brower JP, et al. Educational Exposure to Transgender Patient Care in Plastic Surgery Training. Plastic and Reconstructive Surgery. 2016;138(4):944-53. doi: 10.1097/prs.0000000000002559. PubMed PMID: 00006534201610000-00040. Obedin-Maliver J, Goldsmith ES, Stewart L, White W, Tran E, Brenman S, et al. Lesbian, Gay, Bisexual, and Transgender–Related Content in Undergraduate Medical Education. JAMA. 2011;306(9):971-7. doi: 10.1001/jama.2011.1255. Riesman T, Dacarett-Galeano D, Goldstein Z. Transgender care and medical education. Contemporary Endocrinology 2019. p. 283-92.

Eriksson SES, Safer JD. EVIDENCE-BASED CURRICULAR CONTENT IMPROVES STUDENT KNOWLEDGE AND CHANGES ATTITUDES TOWARDS TRANSGENDER MEDICINE. Endocrine Practice. 2016;22(7):837-41. doi: 10.4158/EP151141.OR.

Safer J, Pearce E. A Simple Curriculum Content Change Increased Medical Student Comfort with Transgender Medicine. Endocrine Practice. 2013;19(4):633-7. doi: 10.4158/EP13014.OR.

Fraser L, Knudson G. Education Needs of Providers of Transgender Population. Endocrinology and Metabolism Clinics of North America. 2019;48(2):465-77. doi: 10.1016/j.ecl.2019.02.008.

Sequeira GM, Chakraborti C, Panunti BA. Integrating Lesbian, Gay, Bisexual, and Transgender (LGBT) Content Into Undergraduate Medical School Curricula: A Qualitative Study. Ochsner Journal. 2012;12(4):379.

Giffort DM, Underman K. The relationship between medical education and trans health disparities: a call to research. Sociology Compass. 2016;10(11):999-1013. doi: 10.1111/soc4.12432. 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):41-5. doi: 10.1007/s40596018-1008-1. James S, Colling Sylvester H. Transgender health and its current omission from medical school curriculum: medical students’ perspective. Advances in medical education and practice. 2018;9:607-9. doi: 10.2147/AMEP.S176532. PubMed PMID: 30214373. Kelley L, Chou CL, Dibble SL, Robertson PA. A Critical Intervention in Lesbian, Gay, Bisexual, and Transgender Health: Knowledge and Attitude Outcomes Among Second-Year Medical Students. Teaching and Learning in Medicine. 2008;20(3):248-53. doi: 10.1080/10401330802199567.

Schechter LS, Cohen M. Gender Confirmation Surgery: A New Frontier in Plastic Surgery Education. Plastic and Reconstructive Surgery. 2016;138(4):784e-5e. doi: 10.1097/prs.0000000000002594. PubMed PMID: 00006534-201610000-00074. Underman K, Giffort D, Hyderi A, Hirshfield LE. Transgender Health: A Standardized Patient Case for Advanced Clerkship Students. MedEdPORTAL : the journal of teaching and learning resources. 2016;12:10518-. doi: 10.15766/mep_2374-8265.10518. PubMed PMID: 30984860. Stanley R. Vance Jr., M.D. a,*, Madeline B. Deutsch, M.D., M.P.H. b, Stephen M. Rosenthal, M.D. c, and Sara M. Buckelew, M.D Enhancing Pediatric Trainees’ and Students’ Knowledge in Providing Care to Transgender Youth.

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Year 4 Research Projects

3rd Annual Communities of Practice Conference

PROPOSED YEAR 4 RESEARCH TOPIC (SYSTEMATIC REVIEWS AND POLICY BRIEFS TO BE DEVELOPED)

Occupational Exposures in Vulnerable Populations Principal Investigator: 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 needs of vulnerable populations experiencing occupation-related health issues in primary care settings. It will employ multiple methods to assess current medical school educational practice, identify evidence-based best practices, and 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 The exposure of farmworkers, one of the vulnerable groups and their dependents to agricultural and residential pesticides is an important public health concern. Their migratory and immigration status limit their access to and utilization of health services. The geographic, financial, and cultural barriers handicap these impoverished populations from seeking medical health care1. Increased awareness among health care professionals, utilizing the services of lay community outreach workers, a stronger public health infrastructure using efficient health care delivery models are expected to alleviate the problem of farm workers to a great extent2. There is a lack of evidence base regarding best strategies in teaching medical students how to screen for and address the needs of vulnerable populations affected by occupational exposure. It is important that medical students understand and are prepared to take steps to address underlying individual, community and socio-economic factors that increase the risk for occupational health issues among 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 occupationally-related health issues in primary care.

HYPOTHESIS »» What evidence exists regarding education of medical students on screening for occupational exposure-related health issues of vulnerable populations in primary care settings? »» What are the core components 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 occupational settings?

PROJECT GOALS »» To identify the extent to which medical students are trained to screen, treat, or refer persons suffering from occupation-related health issues across the life course. »» To develop model curricular elements that can be used by other medical schools to prepare stu-dents to effectively address the needs of vulnerable populations employed in occupational set-tings. »» To disseminate research findings on how medical schools are addressing occupational exposure-related health issues of vulnerable populations to graduate medical education audience.

RESEARCH DESCRIPTION Among the vulnerable populations, exposure of farm workers and dependents to different agrochemicals (pesticides, fertilizers etc.) is unavoidable. In US alone nearly three million farm workers suffer from agricultural chemical exposure, which is a significant occupational risk2. Potential farm work-related health problems include accidents, pesticide-related illnesses, musculoskeletal injuries, soft-tissue disorders, dermatitis, noninfectious respiratory conditions, reproductive health problems, health problems of dependents of farm workers, communicable diseases, bladder and kidney disorders, and eye and ear problems3-6. Even though,

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3rd Annual Communities of Practice Conference

Year 4 Research Projects

the EPA Worker Protection Standard (WPS), which is a federally mandated program requires employers to follow specified waiting periods before allowing workers to enter pesticide-treated areas; to inform workers of the names and potential health consequences of pesticides used; and to supply protective equipment to pesticide handlers, these measures are always not practiced7. Chronic lowlevel exposures lead to long-lasting adverse health effects. However, from a disease etiology standpoint, establishing the patterns of exposure to chemicals; and linking chemical exposures to health outcomes is difficult8-9. Few studies were conducted using biomarkers such as acetylcholinesterase or urinary metabolites to determine exposure10. Even when such information on biomarkers is available, migrant camp conditions, violations in housing regulations, and personal worker behaviors contribute to erroneous data (false positives) among workers not exposed to chemicals and their dependents11. Low socioeconomic status, temporary camps/residential dwellings contaminated with pesticides, and poor access to health care are some of the barriers that contribute to existing health problems in this population12. Studies have shown that health care providers such as medical doctors do not always recognize or respond to issues of occupational exposure issues among vulnerable populations. Study results will be useful in making recommendations for how medical schools should address occupational health issues of vulnerable populations in their curriculum.

POLICY RELEVANCE The current health-care workforce lacks sufficient training on how to screen, and prevent or in cases of occupational exposure, particularly as encountered by vulnerable populations in primary care settings. Little systematic attention has been given to ensuring health care providers are trained to screen for risk factors for occupational exposure that can negatively affect the health of vulnerable populations and lead to disparities in health and healthcare or to initiate appropriate interventions. Academic health centers are equipped to train medical students who will impact the health of vulnerable populations by educating future generations of providers, and delivering integrated care that addresses the unique health needs of these communities

REFERENCES 1. Gwyther ME, Jenkins M. Migrant farmworker children: health status, barriers to care, and nursing innovations in health care delivery. J Pediatr Health Care. 1998;12(2):60-6 2. Hansen E, Donohoe M. Health issues of migrant and seasonal farmworkers. J Health Care Poor Underserved. 2003;14: 153–164. 3. Mobed K, Gold EB, Schenker MB. Occupational health problems among migrant and seasonal farm workers. West J Med. 1992;157(3):367-73. 4. Arcury TA, Quandt SA, Dearry A. Farmworker pesticide exposure and community-based participatory research: rationale and practical applications. Environ Health Perspect. 2001;109 Suppl 3(Suppl 3):429-34. 5. Arcury TA, Quandt SA, Mellen BG. An exploratory analysis of occupational skin disease among Latino migrant and seasonal farmworkers in North Carolina. J Agric Saf Health 2003; 9(3):221-32. 6. Cartwright MS, Walker FO, Newman JC, Schulz MR, Arcury TA, Grzywacz JG, Mora DC, Chen H, Eaton B, Quandt SA. One-year incidence of carpal tunnel syndrome in Latino poultry processing workers and other Latino manual workers. Am J Ind Med. 2014; 57(3):362-9. 7. Salvatore AL, Bradman A, Castorina R, Camacho J, López J, Barr DB, Snyder J, Jewell NP, Eskenazi B. Occupational behaviors and farmworkers’ pesticide exposure: findings from a study in Monterey County, California. Am J Ind Med. 2008;51(10):782-94. 8. Arcury TA, Quandt SA, McCauley L. Farmworkers and pesticides: community-based research. Environ Health Perspect. 2000;108(8):787-92.

9. Gangemi S, Miozzi E, Teodoro M, Briguglio G, De Luca A, Alibrando C, Polito I, Libra M. Occupational exposure to pesticides as a possible risk factor for the development of chronic diseases in humans. Mol Med Rep. 2016; 14(5):44754488. 10. Raymer JH, Studabaker WB, Gardner M, Talton J, Quandt SA, Chen H, Michael LC, McCombs M, Arcury TA. Pesticide exposures to migrant farmworkers in Eastern NC: detection of metabolites in farmworker urine associated with housing violations and camp characteristics. Am J Ind Med. 2014;57(3):323-37. 11. Arcury TA, Lu C, Chen H, Quandt SA. Pesticides present in migrant farmworker housing in North Carolina. Am J Ind Med. 2014; 57(3):312-22. 12. Anderson SE, Meade BJ. Potential health effects associated with dermal exposure to occupational chemicals. Environ Health Insights. 2014; 17;8(Suppl 1):51-62. 13. Johnson A. Amputated Lives: Coping with Chemical Sensitivity. Brunswick, ME: Cumberland Press; 2008 14. Gibson PR, Lockaby SD, Bryant JM. Experiences of persons with multiple chemical sensitivity with mental health providers. J Multidiscip Health. 2016; 9:163-72. 15. 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. 16. Simmons JM, Liebman AK, Sokas RK. Occupational Health in Community Health Centers: Practitioner Challenges and Recommendations. New Solut. 2018;28(1):110-130.

http://NCMEDR.org

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.

• •

•

• • • • •

•

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).

• •

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

•

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

3rd Annual Communities of Practice Conference

Selected Readings on Vulnerable Populations

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

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

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/

http://NCMEDR.org

Selected Readings on Vulnerable Populations 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.

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. 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.

3rd Annual Communities of Practice Conference

http://NCMEDR.org

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/

3rd Annual Communities of Practice Conference 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.

Selected Readings on Vulnerable Populations 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

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4441663/

http://NCMEDR.org

Selected Readings on Vulnerable Populations 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.

3rd Annual Communities of Practice Conference 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.

http://NCMEDR.org

3rd Annual Communities of Practice Conference

Selected Readings on Vulnerable Populations

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.

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/

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

http://NCMEDR.org

Selected Readings on Vulnerable Populations

3rd Annual Communities of Practice Conference

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

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). Thursdayâ€™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 https://link.springer.com/article/10.1007/s00127-014-0854-8

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

http://NCMEDR.org

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

3rd Annual Communities of Practice Conference 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.

Selected Readings on Vulnerable Populations 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

https://www.researchgate.net/publication/297593700_How_Knowledge_ of_Adverse_Childhood_Experiences_Can_Help_Pediatricians_Prevent_ Mental_Health_Problems

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

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4578291/

https://www.ncbi.nlm.nih.gov/pubmed/28609691

Ford, D. E. (2017). The Community and Public Well-being Model: A New Framework and Graduate Curriculum for Addressing Adverse Childhood Experiences. Acad Pediatr, 17(7s), S9-s11. doi:10.1016/j. acap.2017.04.011

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

https://www.academicpedsjnl.net/article/S1876-2859(17)30167-5/abstract

Forstadt, L., Cooper, S., & Andrews, S. M. (2015). Changing Medicine and Building Community: Maine’s Adverse Childhood Experiences Momentum. Perm J, 19(2), 92-95. doi:10.7812/tpp/14-169 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4403584/

Glowa, P. T., Olson, A. L., & Johnson, D. J. (2016). Screening for Adverse Childhood Experiences in a Family Medicine Setting: A Feasibility Study. J Am Board Fam Med, 29(3), 303-307. doi:10.3122/ jabfm.2016.03.150310 https://www.ncbi.nlm.nih.gov/m/pubmed/27170787/

Goldstein, E., Athale, N., Sciolla, A. F., & Catz, S. L. (2017). Patient Preferences for Discussing Childhood Trauma in Primary Care. Perm J, 21. doi:10.7812/tpp/16-055 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5363895/

Goldstein, E., Murray-Garcia, J., Sciolla, A. F., & Topitzes, J. (2018). Medical Students’ Perspectives on Trauma-Informed Care Training. Perm J, 22. doi:10.7812/tpp/17-126 https://www.ncbi.nlm.nih.gov/pubmed/29401053

https://www.tandfonline.com/doi/abs/10.3109/01612840.2015.1074767

Oh, D. L., Jerman, P., Silverio Marques, S., Koita, K., Purewal Boparai, S. K., Burke Harris, N., & Bucci, M. (2018). Systematic review of pediatric health outcomes associated with childhood adversity. BMC Pediatr, 18(1), 83. doi:10.1186/s12887-018-1037-7 http://pediatrics.aappublications.org/content/141/1_MeetingAbstract/309

Olsen, J. M., & Warring, S. L. (2018). Interprofessional Education on Adverse Childhood Experiences for Associate Degree Nursing Students. J Nurs Educ, 57(2), 101-105. doi:10.3928/0148483420180123-07 https://www.ncbi.nlm.nih.gov/pubmed/29384571

Stefanski, K., & Mason, K. (2017). Acing education: pilot curriculum on adverse childhood experiences. Med Educ, 51(11), 1167-1168. doi:10.1111/medu.13436 https://onlinelibrary.wiley.com/doi/full/10.1111/medu.13436

Strait, J., & Bolman, T. (2017). Consideration of Personal Adverse Childhood Experiences during Implementation of TraumaInformed Care Curriculum in Graduate Health Programs. Perm J, 21. doi:10.7812/tpp/16-061 http://www.thepermanentejournal.org/issues/2017/6238-ACE.html

http://NCMEDR.org

Selected Readings on Vulnerable Populations Szilagyi, M., Kerker, B. D., Storfer-Isser, A., Stein, R. E., Garner, A., Oâ€™Connor, K. G., . . . McCue Horwitz, S. (2016). Factors Associated With Whether Pediatricians Inquire About Parentsâ€™ Adverse Childhood Experiences. Acad Pediatr, 16(7), 668-675. doi:10.1016/j. acap.2016.04.013

https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S1876285916301 486?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii %2FS1876285916301486%3Fshowall%3Dtrue&referrer=https:%2F%2Fwww. ncbi.nlm.nih.gov%2F

Tink, W., Tink, J. C., Turin, T. C., & Kelly, M. (2017). Adverse Childhood Experiences: Survey of Resident Practice, Knowledge, and Attitude. Fam Med, 49(1), 7-13. https://www.ncbi.nlm.nih.gov/pubmed/28166574

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

Wen, F. K., Miller-Cribbs, J. E., Coon, K. A., Jelley, M. J., & FoulksRodriguez, K. A. (2017). A simulation and video-based training program to address adverse childhood experiences. Int J Psychiatry Med, 52(3), 255-264. doi:10.1177/0091217417730289 http://journals.sagepub.com/doi/ abs/10.1177/0091217417730289?journalCode=ijpb

TRAUMA INFORMED CARE Cohen, J. A., Berliner, L., & Mannarino, A. (2010). Trauma focused CBT for children with co-occurring trauma and behavior problems. Child Abuse & Neglect, 34(4), 215-224. doi:http://dx.doi.org/10.1016/j. chiabu.2009.12.003 https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S01452134100 00517?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii %2FS0145213410000517%3Fshowall%3Dtrue&referrer=https:%2F%2F www.ncbi.nlm.nih.gov%2F

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

https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S18762859163 05526?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii %2FS1876285916305526%3Fshowall%3Dtrue&referrer=https:%2F%2F www.ncbi.nlm.nih.gov%2F

http://NCMEDR.org

3rd Annual Communities of Practice Conference Finkelhor, D. (2017). Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abuse Negl. doi:10.1016/j. chiabu.2017.07.016

https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S01452134173 02715?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii %2FS0145213417302715%3Fshowall%3Dtrue&referrer=https:%2F%2F www.ncbi.nlm.nih.gov%2F

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

3rd Annual Communities of Practice Conference https://www.cppah.com/article/S1538-5442(15)00102-9/abstract

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

Selected Readings on Vulnerable Populations https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S00313955164 10564?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii %2FS0031395516410564%3Fshowall%3Dtrue&referrer=https:%2F%2F www.ncbi.nlm.nih.gov%2F

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

https://academic.oup.com/cs/article-abstract/25/4/225/567363?redirectedF rom=fulltext

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., & Dâ€™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-

http://NCMEDR.org

Selected Readings on Vulnerable Populations JCOP2290230105%3E3.0.CO%3B2-N

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

http://journals.sagepub.com/doi/ abs/10.1177/0886260515593298?journalCode=jiva

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

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2978167/

https://link.springer.com/article/10.1007/s10578-016-0689-5

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

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3118668/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4490129/

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

3rd Annual Communities of Practice Conference

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https://link.springer.com/article/10.1007%2Fs10597-014-9712-0

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

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), 503520. doi:10.1177/0886260504262961 http://journals.sagepub.com/doi/10.1177/0886260504262961

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

Kim-Godwin YS1, F. J. (2009). Gender differences in intimate partner violence and alcohol use among Latino-migrant and seasonal farmworkers in rural southeastern North Carolina. J Community Health Nurs., 26(3), 131-142. https://www.tandfonline.com/doi/abs/10.1080/07370010903034474

Kim-Godwin, Y. S., Maume, M. O., & Fox, J. A. (2014). Depression, Stress, and Intimate Partner Violence Among Latino Migrant and

3rd Annual Communities of Practice Conference

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

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

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%2Fs10903-014-0007-x

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, MĂŠxico. 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.

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

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

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.

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 providersâ€™ 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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About the Speakers & Content Experts

3rd Annual Communities of Practice Conference

SPEAKERS AND CONTENT EXPERTS Lee A. Aase, BS

Prior to joining Mayo Clinic in 2000, Lee spent more than a decade in political and government communications at the local, state and federal level. He was elected to Mayo Clinic’s Voting Staff in 2016.

of pulmonary hypertension. The nonprofit has developed, KYB Leadership Academy, to expose school students to leadership development while also educating them on pulmonary hypertension, and careers in healthcare. In its first three years, the program travelled to three countries. She is recipient of the prestigious Athena International YP Award (2015), Vanderbilt University Dr. Martin Luther King Jr. Award (2014), and has been inducted into the YWCA Academy for Women of Achievement (2016). She has lectured at academic institutions nationwide (including Johns Hopkins University and Vanderbilt University School of Medicine) and has presented for American Association of Medical Colleges Conference, Beyond Flexner Conference Alliance, and the National Library of Medicine. She serves on the National Minority Health Committee for the American Heart Association; the National Stroke Association; has been National CPR Ambassador for Learn CPR America; and is an external advisory member for the Mayo Clinic Social Media Network.

Thomas A. Arcury, PhD †

Lawrence Bryant, PhD, MPH, BSW, RRT

Thomas A. Arcury, PhD, is Professor in the Department of Family and Community Medicine, Wake Forest School of Medicine. He also directs the Center for Worker Health at Wake Forest School of Medicine. He received his doctoral degree in anthropology from the University of Kentucky in 1983, and completed a post-doctoral fellowship in health services research at the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, in 1995. Since 1996, he has directed a program of research on environmental and occupational health and justice among the families of immigrant workers in rural communities. His contributions have been recognized by, the National Rural Health Association with the 2004 Outstanding Researcher Award, and the National Institute for Occupational Safety and Health with the 2006 Innovative Research Award for Worker Health and Safety. He and Sara Quandt were recognized with the 2017 Defenders of Justice Award for Policy Research and Advocacy by the North Carolina Justice Center, and the 2017 Alice Hamilton Award by the Occupational Health Section of the American Public Health Association.

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, he has received funding from The Georgia Department of Public Health (DPH) to do multicultural needs assessment in support of the Statewide Strategic Plan for Opioid Abuse. Dr Bryant is also a dissertation mentor at Capella University in the School of Nursing and Health Sciences.

Lee Aase is director of the Mayo Clinic Social Media Network, which provides training resources, educational and networking events and a collaboration platform for health care professionals who want to safely and effectively apply social and digital strategies to fight disease, promote health and improve health care. Lee also leads Mayo Clinic’s Social & Digital Innovation team, which manages Mayo Clinic’s presence on general purpose social networks like Facebook, YouTube and Twitter as well as its owned blog and community platform. Key sites include Mayo Clinic Connect, an online patient community, Mayo Clinic News Network, and Sharing Mayo Clinic, a patient stories blog.

Katherine Y. Brown, EdD, OTR/L * Dr. Katherine Y. Brown, EdD, MSEd, BSOT, OTR/L, Assistant Professor, Department of Family and Community Medicine is Director, Communities of Practice for the National Center for Medical Education Development and Research. Her background includes working nationally and internationally with organizations, networks, and agencies, speaking on chronic diseases, health disparities and innovative strategies including faith based health initiatives focused on vulnerable populations.

Millard D. Collins, MD 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.

Using her expertise and national network, she founded Roberta Baines Wheeler Pulmonary Hypertension Awareness Group, in honor of her late mother, to increase awareness

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NCMEDR Consultants

3rd Annual Communities of Practice Conference

About the Speakers & Content Experts

Marvin L. Crawford, MD, MDiv, FACP

Renee S. Frazier, MHSA, FACHE

Marvin L. Crawford, M.D., M.Div., FACP, the Founder and Author of By These Healing Hands Ceremony, is an Associate Professor of Medicine with the Internal Medicine Department and Chaplain of Morehouse School of Medicine, in Atlanta, Georgia. Dr. Crawford is the Senior Pastor of First Saint Paul AME Church in Lithonia, GA.

Renee S. Frazier is an experienced leader in health care management with expertise in hospital operations, managed care, non-profit operations, community service, health promotion, strategic planning, and organizational excellence. She is known for her advocacy towards greater transparency of health care quality indicators, affordable health care, provider report cards, health inequalities and the promotion of health literacy. She has held various national, regional and local COO & CEO positions since the age of 29 and has had operating responsibility for budgets of $5 million to $1 billion.

Marvin L. Crawford, received his B.S. in Biology with honors from Albany State University, Masters of Divinity from Turner Seminary of Interdenominational Theological Center with honors, Doctorate of Medicine from University of Iowa, and residency training at the Medical College of Georgia. He has also studied at Harvard University. He serves as the Director of Student Education/Development in the Department of Internal Medicine of Morehouse School of Medicine, and as a founding faculty member of the Morehouse School of Medicine, Department of Internal Medicine Residency Program. He has served as the Chief of General Internal Medicine, founding Director and Chief of Ambulatory Services, and founding Director of Morehouse Private Hospitalist Services. Dr. Crawford received the nationally sought after John Templeton’s Foundation grant for his spirituality and medicine curriculum. He has been a national guest panelist and speaker on spirituality and mental health. He is noted to be a compassionate and excellent teacher to residents and students, receiving multiple awards for his classrooms and bedside teachings. He has lead the efforts to modify and update the Morehouse School of Medicine, Department of Internal Medicine student’s curriculum and expand the Internal Medicine Clerkship.

Robert DiPaola, MD Dr. DiPaola is the Dean of the College of Medicine at the University of Kentucky and Vice President of Clinical Academic Affairs for UK HealthCare. With considerable experience in the area of translational research and a primary focus on the study of prostate cancer, he was one of the earliest investigators to target the degradation of bcl-2/apoptosis and autophagy/ cancer metabolism in the laboratory and clinic as a means to restore drug sensitivity in prostate cancer; and clinical studies that have had impact on standards of care, including studies published as senior author in high impact journals including the New England Journal of Medicine (2015) and Lancet (2016). At the University of Kentucky as Dean he leads and manages all aspects of operations of the College of Medicine with approximately 1,000 full-time faculty; is leading efforts of a state-wide, four-year program campus expansion program in Bowling Green and Northern Kentucky; has been a leader on LCME site visit reviews; launched new educational and research initiatives that have led to increased federal research funding (over 30 percent increase in 2017-2019); and is one of four vice presidents as executive leadership within UK HealthCare, a $1.6 billion health care system.

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NCMEDR Consultants

Angelica G. Fugerson, DrPH, MPH Dr. Angelica Geter is an Adjunct Professor of Morehouse School of Medicine. She earned her DrPH in Health Behavior with a minor in Biostatistics from the University of Kentucky and her MPH in Behavioral Sciences and Health Education from Emory University. She is also an alumna of the Health Policy Leadership Fellowship of the Satcher Health Leadership Institute. Her research has focused on HIV disparities in the South and sex trafficking prevention in vulnerable communities. Dr. Geter is committed to being a servant leader by telling the stories of southern populations through research, policy development and the advancement of health equity. She has published more than 20 articles and presented at numerous national and international scientific meetings.

Wesley Geminn, PharmD, BCPP Dr. Geminn is currently serving as Tennessee’s State Opioid Treatment Authority which is responsible for providing regulatory oversight, education, and clinical and technical assistance to Tennessee’s opioid treatment programs. As the Chief Pharmacist, he also provides assistance and oversight to regional mental health institute’s pharmacy services and serves on several departmental committees responsible for improving patient care for all those served by the department.

The Honorable Brenda Gilmore Brenda Gilmore was elected State Senator, District #19 for the State of Tennessee, November 2018. She is a former Metro Council Woman and served as State Representative, District #54, in the Tennessee General Assembly for twelve years. Brenda has also formerly served on the Board of the John F. Kennedy Susan Gray School for Children who have been abused and with special needs; Chairperson, Board of Margaret Cunningham Women’s Center; Advisor, and Undergraduate Chapter of Delta Sigma Theta Sorority. Other community involvements have included Chairperson for the United Negro College Fund Volunteer Committee. She has served as the President of the Senior Citizen Inc. Board; the Board of Directors of Skyline Medical Center and Trustee for the Belmont Board of Trust.

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About the Speakers & Content Experts Jillian Hopewell, MPA, MA

Patricia Matthews-Juarez, PhD *

Jillian Hopewell, MPA, MA has devoted her professional career to health care justice for immigrant populations. Ms. Hopewell directs MCN’s West Coast office, serving as the national Director of Education and Communication. In this capacity, Ms. Hopewell oversees MCN’s comprehensive technical assistance program for migrant and community health centers and migrant clinicians. She also directs MCN’s continuing education program for clinicians and coordinates all of MCN’s clinical publications. Ms. Hopewell is an adjunct faculty member of the Communication Arts & Sciences Department at California State University, Chico.

Dr. Matthews-Juarez has extensive experience in medical education, research training, administration and management. She established the first office of Faculty Affairs and Development in the School of Medicine and at the institutional level at Meharry Medical College (Meharry). Her past academic positions have included the administrator for the Meharry-Morehouse-Drew Consortium Cancer Center. In this role, she co-authored the first national grant for the National Black Leadership Initiative on Cancer. She was the vice chair/administration for the Department of Family and Community Medicine at Charles R. Drew University of Medicine and Science. Most recently, she was the cofounding director of the Research Center on Health Disparities, Equity, and the Exposome, University of Tennessee Health Science Center in Memphis, Tennessee and Professor in the Department of Preventive Medicine. Currently, she is the vice president for the Office of Faculty Affairs and Development and tenured professor in the Department of Family and Community Medicine at Meharry. She is the project director for two HRSA grants: The College-wide Patient-Centered Medical Home Project and the Primary Care Training and Enhancement/ Academic Unit Project: National Center on Medical Education Development and Research.

Wansoo Im, PhD * Dr. Im is Associate Professor of Family & Community Medicine at Meharry Medical College and Director of the National Community Mapping Institute within the Health Disparities Research Center of Excellence (HDRCOE) at Meharry. He also serves as Director of Dissemination for the National Center for Medical Education Development and Research. He specializes in developing decision support systems using a public participatory approach to Geographic Information Systems (GIS). He has pioneered the use of interactive, web/mobilebased GIS to support community-based participation and research on a wide range of social and environmental issues. Dr. Im previously served as co-director of the Environmental Health Core of the HDRCOE at Meharry. He joined the faculty at Meharry Medical College on a full time in 2016 to lead the National Community Mapping Institute and curate public health exposome data with complete metadata

Paul D. Juarez, PhD * Paul D. Juarez, PhD. 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 and 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).

3rd Annual Communities of Practice Conference

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Leandro A. Mena, MD, MPH † 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 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 Evers-Williams 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 co-founded Open Arms Healthcare Center (first LGBT clinic in Mississippi). In recognition to his work developing a model program of culturally-competent 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. Dr. Mena’s work has been featured in medical and public health journals such as Clinical Infectious Diseases, Sexually Transmitted Diseases, Sexually Transmitted Infections, Journal of Acquired Immunodeficiency Syndrome, and American Journal of Public Health. He 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.

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NCMEDR Consultants

3rd Annual Communities of Practice Conference

About the Speakers & Content Experts

Freida H. Outlaw, PhD, RN, APRN, FAAN

Renay Scales, PhD

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.

Dr. Renay Scales has served as a senior administrator and faculty for over thirty years. She has been employed in health care, at one of the largest electrical utility companies in the country, and in higher education.

Asa Radix, MD, MPH Dr. Radix is the Senior Director of Research and Education at the Callen-Lorde Community Health Center and a Clinical Associate Professor of Medicine at New York University. Originally from the West Indies, Dr. Radix trained in internal medicine and infectious disease at the University of Connecticut and obtained postgraduate degrees in epidemiology and public health at Cambridge University. Dr. Radix has over 20 years of experience providing HIV care, primary care and hormone therapy to transgender and gender non-binary people and is a recognized expert in transgender medicine. At Callen-Lorde Dr. Radix is also the clinical director of the center’s Transgender Health Program that provides care to over 4000 transgender and gender non-binary individuals. Dr. Radix has contributed to multiple national and international guidelines in transgender health and is currently Co-Chair of the World Professional Association of Transgender Health (WPATH) Standards of Care version 8 working group. Dr. Radix is member of several boards/committees including the New York State AIDS Institute STI Quality Advisory Committee, the HHS Panel on Antiretroviral Guidelines for Adults and Adolescents, the Pan American Health Organization HIV/STI Technical Advisory Committee, the American Sexual Health Association, USPATH steering committee, and the medical advisory board of the UCSF Center of Excellence in Transgender Health. Dr. Radix is an Associate Editor of Transgender Health and serves on the editorial board for the International Journal of Transgenderism.

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NCMEDR Consultants

Dr. Scales’ primary roles have been in human resources, labor relations, corporate training, and faculty and curriculum development. In the last twenty years, she has worked on three presidential teams, and taught courses at the community college, undergraduate and graduate levels in management and leadership, most recently teaching graduate classes in higher education.

Marybeth Shinn, PhD † 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, co-authored 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.

Angela W. Walter, PhD, MPH, MSW Angela Wangari Walter, PhD, MPH, MSW is an Assistant Professor of Public Health in the Department of Public Health, at the Zuckerberg College of Health Sciences, University of Massachusetts Lowell. Dr. Walter’s research and practice aim to advance science and practice in ways that will redress racial and ethnic inequities in the access to and quality of health care and social services. Her current projects focus on: the prevention and treatment of co-occurring mental illness and substance use disorders; pre-arraignment adult diversion alternatives in the justice system; coordination and integration of primary care, specialty care and social service systems in care delivery systems such as accountable care organizations; and implementation science of the Gabby Preconception Care system - an innovative communication system designed to identify and mitigate health risks for young Black and African American women before pregnancy, as a means of reducing racial health disparities in birth outcomes. She has practice experience in health care delivery systems and in developing, implementing and evaluating systems of care for complex populations. Dr. Walter is involved with several community and non-profit organizations working on racial and social justice issues serving as a volunteer, advocate, board and advisory member

http://NCMEDR.org

About the Speakers & Content Experts

3rd Annual Communities of Practice Conference

Rueben C. Warren, DDS, MPH, DrPH, MDiv

Suzanne L. Wenzel, PhD

Rueben C. Warren, D.D.S., M.P.H., Dr. P. H., M. Div., is professor and director of the Tuskegee National Center for Bioethics. Adjunct appointments: professor of public health, medicine and ethics, Interdenominational Theological Center; clinical professor, Department of Community Health/Preventive Medicine, Morehouse School of Medicine; professor, Department of Behavioral Sciences and Health Education, Emory’s Rollins School of Public Health; and professor, Schools of Dentistry and Graduate Studies, Meharry Medical College. Dr. Warren was associate director for Minority Health, Centers for Disease Control and Prevention. He directed Infrastructure Development, National Center on Minority Health and Health Disparities, NIH. Formerly, he was dean of the Meharry Medical College School of Dentistry.

Suzanne L. Wenzel, PhD, is the Richard and Ann Thor Professor in Urban Social Development in the Dworak-Peck School of Social Work, University of Southern California. With sponsorship from the National Institutes of Health and other entities, she has conducted research over two decades to understand and address the behavioral health, social, community, and service needs of persons marginalized by homelessness. Most recently, she led research sponsored by the National Institute on Drug Abuse to understand changes over time in health, health behaviors, social relationships, and service access and experiences among persons who had experienced homelessness and were living in permanent supportive housing in Los Angeles. In 2009, she consulted for the White House Office of National AIDS Policy regarding the role of housing in supporting HIV prevention. She has served on study sections for the National Institutes of Health and participated in a National Academies of Sciences, Engineering and Medicine panel investigating health outcomes for persons living in permanent supportive housing. She is a fellow in the Association for Psychological Science and has published more than 100 peer-reviewed journal articles.

G. Robert Watts, MPH, MS, CPH Bobby Watts is the Chief Executive Officer of the National Health Care for the Homeless Council, which supports the 300 federally-funded Health Care for the Homeless programs and also Medical Respite providers with training, technical assistance, sharing of best practices, research, publications, and an active policy and advocacy program working to eliminate homelessness. Bobby has 30 years of experience in administration, direct service, and implementation of homeless health services, beginning as a live-in counselor at the New York City Rescue Mission in Manhattan. He spent most of his career prior to joining the Council at Care for the Homeless, which operates clinics, shelters, and conducts policy analysis and advocacy in NYC, beginning as an intern, and serving as the Executive Director from 2005-2017. Under his tenure, the Federally Qualified Health Center agency tripled in size, adding major programs and initiatives –including constructing and operating a shelter for 200 mentally ill and medically frail women –and becoming licensed as a Diagnostic and Treatment Center in New York State. He has served on numerous boards, government-appointed task forces, and workgroups including serving as the Finance Officer for the NYC HIV Health and Human Services Planning Council, and as an inaugural member of the NYS Interagency Council on Homelessness.

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NCMEDR Consultants

Faculty, Staff, & Partners

3rd Annual Communities of Practice Conference

FACULTY, STAFF, & COMMUNITY PARTNERS Lee A. Aase, BS

Communications Director Public Affairs Mayo Clinic Austin, MN

Holly Andrilla, MS

Research Scientist Family Medicine University of Washington Seattle, WA

Monique Anthony, MPH

Director Tennessee Department of Health, Office of Minority Health and Disparities Elimination Nashville, TN

Thomas A. Arcury, PhD †

Professor Family and Community Medicine Wake Forest School of Medicine Winston-Salem, NC

April D. Barnes, RN

Linda A. Clayton, MD, MPH

Medical Director Reproductive and Women’s Health Tennessee Department Health Nashville, TN

Spencer Coats, MSW, MPH, CPT Director of Health and Wellness Health and Wellness Downtown Women’s Center Los Angeles, CA

Millard D. Collins, MD

Chair and Associate Professor Family & Community Medicine Meharry Medical College Nashville, TN

Robert L. Cooper, PhD * Assistant Professor Meharry Medical College Nashville, TN

Marvin L. Crawford, MD, MDiv, FACP Director of Student Education Internal Medicne Morehouse School of Medicine Atlanta, GA

Director Outreach The Next Door Clarksville, TN

Sandra L. Bosmans, BSN Clinical Nurse Supervisor Dept of Army 7229th Medical Support Unit Pleasant View, TN

Katherine Y. Brown, EdD, OTR/L *

Assistant Professor, Director, Communities of Practice Family and Community Medicine Meharry Medical College / National Center for Medical Education Development and Research Nashville, TN

Kimberly L. Brown

Scottie B. Day, MD Chair Pediatrics University of Kentucky Lexington, KY

Robert DiPaola, MD

Dean of the College of Medicine/VP Academic Medicine College of Medicine University of Kentucky Lexington, KY

Margarita Echeverri, PhD, MSc

Project Associate 1Joshua Group, LLC Atlanta, GA

Assistant Professor College of Pharmacy Xavier University of Louisiana New Orleans, LA

Lawrence Bryant, PhD, MPH, BSW, RRT

Christopher T. Fitzpatrick

Assistant Professor Health Promotion, Physical Education Kennesaw State University Decatur, GA

Kristen N. Campbell Project Associate 1Joshua Group, LLC Atlanta, GA

Roberto B. Cardarelli, DO, MHA, MPH

Professor and Chair Department of Family & Community Medicine University of Kentucky College of Medicine Lexington, KY

Janeth Ceballos Osorio, MD Assistant Professor of Pediatrics Department of Pediatrics Universtiy of Kentucky Lexington, KY

* NCMEDR Faculty |

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NCMEDR Consultants

Program Director 1Joshua Group, LLC Atlanta, GA

Renee S. Frazier, MHSA, FACHE CEO Emeritus Commontable Health Alliance Olive Branch, MS

Angelica G. Fugerson, DrPH, MPH Adjunct Professor Morehouse School of Medicine Atlanta, GA

Wesley Geminn, PharmD, BCPP

Chief Pharmacist Clinical Leadership Tennessee Department of Mental Health and Substance Abuse Services Nashville, TN

The Honorable Brenda Gilmore Senator, D-19th District State of Tennessee

Bridgette L. Hickey

Commander 7229th Medical Support Unit Smyrna, TN

Cheryl L. Holder, MD

Associate Professor Herbert Wertheim College of Medicne Miami, FL

Jillian Hopewell, MPA, MA

Director of Education and Communication Migrant Clinicians Network Chico, CA

Ruben A. Hopwood, PhD

Director Hopwood Counseling & Consulting Cambridge, MA

Wansoo Im, PhD *

Associate Professor Family and Community Medicine Meharry Medical College Nashville, TN

Paul D. Juarez, PhD *

Professor Family & Community Medicine Meharry Medical College Nashville, TN

Patricia Matthews-Juarez, PhD *

Senior VP, Faculty Affairs & Development, Director, Research Training Core, Health Disparities Research Center of Excellence Meharry Medical College Nashville, TN

Leandro A. Mena, MD, MPH †

Professor Population Health Science John D. Bower School of Population Health, University of Mississippi Medical Center Jackson, MS

Stephania T. Miller-Hughes, PHD, MS, MSCI Associate Professor Surgery Meharry Medical College Nashville, TN

Lori Miller, RN

Nurse US Army Reserves 7229th Medical Support Unit Nashville, TN

Matthew C. Morris, PhD *

Associate Professor Family and Community Medicine Meharry Medical College Nashville, TN

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Faculty, Staff, & Partners Christian Neal

Executive Associate Meharry Medical College Nashville, TN

Freida H. Outlaw, PhD, RN, APRN, FAAN Executive Academic Consultant Minority Fellowship Program/American Nurses Association Nashville, TN

Michael J. Paul, MPH

Program Coordinator Family & Community Medicine Meharry Medical College Nashville, TN

3rd Annual Communities of Practice Conference Jayne S. Reuben, PhD

Director, Instructional Effectiveness Academic Affairs Texas A&M University College of Dentsitry Dallas, TX

Cecil F. Ross, MPH

Executive Officer Dept of Army 7229th Medical Support Unit Hendersonville, TN

Irene Sandvold

Health Resources and Services Administration

Renay Scales, PhD

President 1Joshua Group, LLC Atlanta, GA

Associate Dean, Diveristy and Inclusion Associate Professor, Family and Community Medicine University of Kentucky Lexington, KY

John T. Pennington, PhD

Marybeth Shinn, PhD †

Kermit G. Payne

Amy F. Turk, LCSW

Chief Innovation Officer Downtown Women’s Center Los Angeles, CA

Vikki Ann Vickers

Advocate Downtown Women’s Center Los Angeles, CA

Angela W. Walter, PhD, MPH, MSW Assistant Professor Public Health University of Massachusetts Lowell Lowell, MA

Rueben C. Warren, DDS, MPH, DrPH, MDiv

Professor and Director National Center for Bioethics In Research and Health Care Tuskegee University Tuskegee, AL

Professsor Human and Organizational Development Vanderbilt University Nashville, TN

G. Robert Watts, MPH, MS, CPH

Asa Radix, MD, MPH

Arianna Sholes-Douglas, MD

Shelia J. Webb, PhD, APRN, CNS

Aramandla Ramesh, PhD *

Natalie K. Stevenson

Suzanne L. Wenzel, PhD

Professor Psychology Middle Tennessee State University Murfreesboro, TN Director of Research and Education Medicine Callen-Lorde Community Health Center New York, NY Associate Professor NCMEDR Meharry Medical College Nashville, TN

Linda C. Redd, MSHSA, MBA Program Director Faculty Affairs and Development Meharry Medical College Nashville, TN

Medical Director Integrative Medicine and Gynecology Tula Wellness and Aesthetics Tucson, AZ Program Manager Meharry Medical College Nashville, TN

Mohammad A. Tabatabai, PhD *

Professor of Biostatistics School of Graduate Studies and Reseach Meharry Medical College Nashville, TN

Machelle F. Thompson, RDH, MSPH

CEO National Health Care for the Homeless Council Nashville, TN COO/Associate Clinical Director Administration EXCELth, INC New Oleans, LA

Richard and Ann Professor in Urban Social Development Dworak-Peck School of Social Work University of Southern California Los Angeles, CA

Tiffinie Zellars, DNP, MSPH, RN

PCMH Director/Nurse Educator/QI Nurse Meharry Medical College Nashville, TN

Assistant Dean Compliance & Outcomes Assessment Meharry Medical College Nashville, TN

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* NCMEDR Faculty |

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NCMEDR Consultants

http://NCMEDR.org

The Primary Care Training and Enhancement Academic Units (AU) project is supported in part through a co-operative 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 author 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.

Meharry Medical College National Center for Medical Education Development and Research 1005 Dr. D.B. Todd Jr. BLVD, Nashville, TN 37208 www.NCMEDR.org

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