To provide perspectives from heterogenous cisgender immigrant women and service providers for immigrants in New York City (NYC) on how restrictive sexual and reproductive health (SRH) care delivery environments during COVID-19 shape immigrant's access to health care and health outcomes to generate insights for clinical practices and policies for immigrant women's health care needs.A qualitative study was conducted in 2020 and 2021, including in-depth interviews with 44 immigrant women from different national origins and 19 direct service providers for immigrant communities in NYC to explore how immigrants adapted to and were impacted by pandemic-related SRH care service delivery barriers. Interviews were coded and analyzed using a constant comparative approach.Pandemic-related delays and interrupted health care, restrictive accompaniment policies, and the transition from in-person to virtual care compounded barriers to care for immigrant communities. Care delays and interruptions forced some participants to live with untreated health conditions, resulting in physical pain and emotional distress. Participants also experienced challenges within the health care system because of changes to visitor policies that restricted the accompaniment of family members or support persons. Some participants experienced difficulties accessing telehealth and technology, while others welcomed the flexibility given the demands of frontline work and childcare.To mitigate the health and social implications of increasingly restrictive immigration, reproductive, and social policies, clinical practices like expanding access to care for all immigrants, engaging immigrant communities in health care institutions policies and practices, and integrating immigrant's support networks into care play an important role. Before the COVID-19 pandemic, women in immigrant and minoritized communities had greater barriers accessing sexual and reproductive health (SRH) care,4 reported poorer quality of care,6 and experienced poorer SRH outcomes than the US-born population.4 The limited existing literature7 on immigrants' SRH primarily focuses on prenatal care and gynecological cancer screening practices, with less of a focus on SRH experiences and fertility, contraception, and abortion.8 Furthermore, while immigrant populations face well-known social, economic, and political barriers to obtaining SRH care, these barriers stem from intersecting consequences of structural inequalities, xenophobic immigration policy, and racism,9–12 which are rarely the focus of immigration SRH research.3More than 44 million immigrants and 8 million citizens with at least one undocumented family member live in the United States.14 During COVID-19, SRH services, which are essential primary care, were negatively impacted by shifting priorities within health care systems.15COVID-19 offers a glimpse into the consequences of structural barriers for immigrant access to SRH care. SRH care is an important emphasis of study, given the pervasive impact of oppressive structures and restrictive policy making that leave SRH care uniquely inaccessible and stigmatized relative to other aspects of health and health care.15 Access to SRH care was further reduced by loss of health insurance and wages due to pandemic-related job losses and fears of exposure to the virus.16 There were also lower rates of sexually transmitted infection screening, reduced access to contraception and abortion care, and reduced access to services for intimate partner violence (IPV).18 Yet little is known about how these changes in SRH service delivery during COVID-19 were experienced among immigrant communities.19Studies with service providers demonstrated the scope of tremendous interruptions to SRH services through shifts from in-person to virtual visits, supply chain disruptions, and reduced staffing.To fill this gap in knowledge among a large, underserved population in the United States, we conducted a qualitative study among a unique sample that includes both cisgender immigrant women from diverse national origins and direct service providers for immigrant communities in New York City (NYC). We use the perspectives of immigrant women and direct service providers to describe immigrant women's experiences of disruptions in SRH care delivery during COVID-19 and discuss clinical and policy implications.A qualitative study, including semistructured, in-depth interviews, was conducted with cisgender immigrant women in NYC from several regions and countries of origin and direct service providers who serve immigrant communities from all five boroughs . Interviews explored experiences of SRH care services among women and providers during the first and second years of the COVID-19 pandemic (September 2020–May 2021). Institutional Review Board (IRB) approval was received for the study (AAT2404). Recruitment of the immigrant sample began in August 2020 and interviews were completed by March 2021. Community-based organizations (CBOs) that work with and provide services  for immigrant communities facilitated recruitment by identifying participants, posting flyers, and distributing emails to their clients. Recruitment for direct service providers began in March of 2021 and concluded in May of 2021. The CBOs that facilitated recruitment for immigrant women also facilitated initial outreach for service provider interviews, and additional service provider participants were recruited through snowball sampling.The interview guides were developed by the study team based on the literature on immigrants' SRH and access to health care and revised and finalized after initial interviews. Interviews were conducted in either English or Spanish, depending on participant preference, through Zoom video or phone calls per participant preference. Spanish interviews were conducted by one of the bilingual investigators on the research team. Interviews lasted 45–60 minutes and were audio recorded. Each participant received an information sheet about the study and provided verbal consent for participation and audio recording before the interview. Participants were given a $50 Amazon gift card for their participation in the study.Recordings in English were transcribed using transcription software and transcripts were manually compared with the audio recording for accuracy. A certified transcriber and certified translator transcribed and translated the Spanish interviews to English. We utilized separate coding and analytic processes for each sample. Codebooks were developed with a subset of each sample's transcripts using a line-by-line approach to identify prominent themes and patterns. Thematic codes based on existing literature were also integrated into the codebooks. Several rounds of codebook revisions were conducted until there was a high level of agreement among the study team about the meaning and application of codes.Dedoose. Data for both samples were analyzed using a constant comparative method,20 which is an iterative process of continuously reviewing data alongside emergent themes and patterns until core categories and relationships between categories are identified. The study investigators developed an initial codebook that was revised, finalized, and applied with a four-member study team through an iterative coding and meeting process to review and resolve codes, questions, and discrepancies. This helped ensure validity and consistency of coding across team members and identification of all possible themes. Once all transcripts were coded, we identified and described themes and narratives that emerged around immigrant women's and direct service providers' experiences with SRH care service delivery during COVID-19. Common themes across the two samples were combined using detailed memos and study team meetings to generate cross-sample thematic results.Transcripts were deidentified, uploaded, and coded using The sample includes 44 immigrant women and 19 direct service providers. Sample characteristics are provided in Participants explained how they contended with a range of SRH concerns over the course of the pandemic. When asked if they experienced any change in their SRH during the COVID-19, 12 (27%) women reported changes in their menstruation, including early and late onset of periods, missed periods, irregular bleeding, and increased menstrual pain. Eight women (18%) reported other ailments, including vaginal yeast infections, pain during intercourse, and obstetric complications. And others were receiving care for problems diagnosed before the pandemic, including thyroid cancer, breast cysts, uterine fibroids, and an abnormal cervical cancer screening.e.g., asthma, metabolic disorders) and eight reported a history of IPV. Most participants reported experiencing mental health distress, such as sadness or anxiety, and some described mental health illnesses, including depression, substance use disorders, and eating disorders. Below, we describe the main SRH service delivery barriers that emerged for immigrants and providers, including the consequences of delayed and interrupted health care, harm from restrictive accompaniment policies, and mixed experiences with transition to telehealth. Fifteen participants reported managing current chronic illnesses  and abortion care. Some providers described how abortion was still accessible, but often delayed to later in pregnancy.Respondents discussed the negative impact of cancelled and delayed health care appointments on women's SRH during the pandemic, including decreased access to family planning services and delayed chronic illness management. Respondents noted challenges for immigrant women in need of services, which required in-person clinic visits, such as the insertion or removal of long-acting forms of contraception  had experienced a recurrence of thyroid cancer; when the pandemic started, her radiation therapy came to an abrupt halt. Another woman  had to postpone surgery to remove uterine fibroids, resulting in additional months of heavy bleeding, while she was juggling securing work and her childcare needs.Care delays and interruptions forced some immigrant women to live with untreated health conditions, resulting in physical pain and mental health distress. One participant  associated with delayed care and untreated conditions because they did not have family in the United States. One woman , for example, who had recently given birth, had to wait 6 months for an operation to repair an obstetric fistula after the surgeon was diagnosed with COVID-19.Immigrant women described having very limited social support to help address the physical, emotional, and logistical needs  described how her mother put off a necessary surgery to remove gynecologic cysts because of the fear of going through the procedure alone. Another participant  was so afraid to seek care without the support of a family member that she waited until her daughter's dental appointment to ask for professional assistance for what was later diagnosed as extreme anxiety. She said that she was “embarrassed to talk to people,” so she told her daughter, “You speak to them in English and I'll tell you what to say…”One participant Some women were forced to forgo medical appointments because visitor policies prohibited them from bringing their children and they had limited or no childcare. Out of the 24 women with children in our sample, 15 (63%) were separated, divorced, or single and the primary caretaker of their children and even those in partnerships were often the primary caretaker and worked to support the family.39 years old, Mexico), for instance, described the difficult decision she was forced to grapple with when both of her children became ill in the early months of the pandemic. “I thought that if I went [to the hospital], they would possibly isolate them from me because they would not allow any family members to be there. I panicked, I was afraid, I decided to leave them at home.”Many participants expressed a profound fear of being isolated and separated from their children if they or their children were to require hospitalization. For some, this fear informed their decisions to forego care when they themselves or their children were ill, even if they thought it was necessary. One participant , for example, attended a virtual consultation with a physician after her menstrual cycle was delayed for over 2 months. Even though she was diagnosed with a menstrual disorder, she continued to be concerned with her cycle. When asked about her experience with the telehealth appointment, she replied: “I was always in doubt, because the doctor only looked at my face, he didn't look at my body, how does he know that's what it was?”Women and providers shared concerns about whether the quality of virtual care was like in-person care. One woman , these visits provide an opportunity for women to discuss a range of health and social concerns and for providers to assess other health and social needs, including safety, therefore serving as a principal entry point for connecting women to primary and specialty care, mental health, and other social resources. As evidenced by our results, immigrant women may use their children's health care visits to access their own care, and others described their fear of being separated from their children during health care encounters. Study data further confirm the importance of both primary care and SRH care to fully support the comprehensive needs of immigrant women and their families.40Although women may seek out SRH care for SRH reasons (The study was conducted in NYC and generalizability to health care systems and populations elsewhere is limited. However, there is a critical lack of data on health care behaviors among immigrant communities, particularly those who lack documentation. We highlight important considerations for health care settings that serve immigrant populations, including expanding access to care for all immigrants, engaging immigrant communities in health care institutions policies and practices, and integrating immigrant's support networks into care. More research about how to deliver health care, whether SRH care specifically or primary care, is needed to mitigate the health and social implications of increasingly restrictive immigration, reproductive, and social policies.


This article was migrated. The article was marked as recommended.The current Coronavirus Disease 2019 (COVID-19) pandemic has strained hospital systems and training programs across the world. As capacity issues mount and trainees are called upon to provide frontline medical care, programs and institutions have had to rapidly evolve to redefine the trainee experience. To that end, there is a paucity of literature regarding how healthcare training programs should operate during a global pandemic. Here, we aim to describe twelve evidence-based recommendations for coordinating a cohesive, systematic approach to pandemic response planning for Internal Medicine residency training programs. These tips encompass inpatient and outpatient practices, provider safety, resuscitation, virtual education programming and resident wellbeing. Though many of these considerations or recommendations were not described during the COVID-19 pandemic, these tips have been described previously in the literature, are applicable to the current pandemic and could be easily extrapolated to future crises. On March 11, 2020, the World Health Organization declared Coronavirus Disease 2019 (COVID-19) a global pandemic. As of May 27, there have been 5,488,825 cases of COVID-19 with 349,095 deaths, and the numbers are still multiplying . The COVThere is little available data to advise healthcare training programs on best practices and procedures during this global pandemic. Though some literature exists regarding training program operations during the severe acute respiratory syndrome (SARS) and Middle Eastern respiratory syndrome (MERS) outbreaks , these eOver the past several weeks, more and more is being written about the impact of the virus on various training programs and their trainees . DespiteDuring pandemic planning, program leadership needs to make effective use of existing team members including program directors, chief residents, program administrators and key faculty while extending expertise by tapping into new and existing contacts within and outside the local institution. The program director should not take primary responsibility for all decisions or tasks. Increased delegation to content experts concerning resident schedules, changes to inpatient and outpatient services, adjustments to structured educational offerings, instructions and monitoring of safety practices and policies and best practices for clinical care should be considered. A shared approach distributes the time burden involved to address the multiple facets involved in crisis planning . InvolviIn response to a pandemic, hospitals must strategize and implement a preparedness plan focused on patient triage, care capacity and provision of appropriate staffing during a potential patient surge. Fundamental to this effort is the formulation of an operations task force including key frontline personnel . InternaWhen involved in hospital preparedness working groups, Internal Medicine residency programs have the opportunity to collaborate with hospital leadership to ensure that preparedness plans abide by regulations imposed by training oversight committees and meet the common goal of providing safe and effective patient care. Programs need to be aware of which key stakeholders anticipate having Internal Medicine resident support in the event of a patient surge to effectively operationalize resident deployment. Attention should be paid to trainee safety and supervision, appropriate provider to patient ratios and adherence to imposed regulations. Lastly, programs should reflect on their core values and ensure that these specific values are also supported.There is not yet consensus surrounding the extent to which resident and fellow trainees should be shielded from participating in the care of patients infected with COVID-19. In the United States, the Accreditation Council for Graduate Medical Education (ACGME) supports trainee involvement in the care of COVID-positive patients if they receive adequate training in infection control and disease management, comply with established work hour restrictions and receive direct supervision from faculty . DependiWith the potential for a steep influx of ill patients, it is critical to be able to expand inpatient service lines with a particular focus on critical care units to meet evolving health system demands. In a prevailing pandemic care model, as the patient surge intensifies, additional providers with appropriate training should be deployed in a tiered fashion to increase service line capacity . ResidenRegardless of a health system’s anticipated trainee involvement in the care of patients infected with COVID-19, appropriate education on hand hygiene and utilization of PPE is of upmost importance. Incorrect use of PPE increases trainee exposure risk and could contribute to COVID-19 transmission. Despite its critical importance in protecting healthcare providers and patients, studies suggest that errors in donning and doffing PPE occur frequently . In a siRecent estimates suggest that the mortality rate of COVID-19 is approximately 3%  and mortInpatient rounds are the cornerstone of inpatient medical care and medical education in teaching hospitals. Medical educators have advocated for attending rounds to be conducted at the bedside to enhance teaching, allow for learner assessment, improve communication and optimize patient-centered care . With soMiscommunications during patient handoffs between trainees is a leading cause of medical errors. The ACGME Clinical Learning Environment Review outlines the need for education in care transitions and standardized handoffs in resident education . StudiesIn the era of COVID-19, the need for social distancing has provided an additional challenge when it comes to standardized care transitions between trainees who often work in confined spaces and gather in groups during handoff. It is imperative to establish a protocol for effective and safe patient care transition while protecting trainees from unnecessary exposure. Trainees can be encouraged to adhere to social distancing guidelines by conducting handoffs via phone or video communication, maintaining updated written sign-outs in the electronic medical record for cross-covering teams to reference and communicating via standardized formats to ensure safe transitions of care.As significant adjustments are made to inpatient operations, training programs should also adapt their ambulatory care practices and curriculum to meet the needs of patients, trainees, clinic staff and faculty preceptors. Clinic schedules should be modified to decrease the burden of in-person visits in an effort to minimize COVID-19 exposure risk while continuing to provide optimal patient care. Rescheduling non-urgent appointments and converting appointments to telehealth or virtual visits as clinically appropriate allows for a decrease in onsite staffing while allowing for primary care access . TruncatInternationally the use of telehealth has rapidly increased to meet the unique challenges posed by the COVID-19 pandemic . HealthcThe COVID-19 pandemic has forced residency programs nationwide to suspend in-person educational activities and rapidly innovate virtual education curricula. As resident wellness and sense of community is negatively impacted by the disruption of conventional face-to-face conferences, programs should aim to transition their regular interactive didactics to interactive web-based platforms . Core liBy virtue of their role within the health system, residents are at high risk for developing burnout during periods of routine operation  let alonKnobler HY, Nachshoni T, Jaffe E, Peretz G, Yehuda YB. Psychological guidelines for a medical team debriefing after a stressful event. Mil Med. 2007;172(6):581-5.Knobler HY, Nachshoni T, Jaffe E, Peretz G, Yehuda YB. Psychological guidelines for a medical team debriefing after a stressful event. Mil Med. 2007;172(6):581-5.Knobler HY, Nachshoni T, Jaffe E, Peretz G, Yehuda YB. Psychological guidelines for a medical team debriefing after a stressful event. Mil Med. 2007;172(6):581-5.Knobler HY, Nachshoni T, Jaffe E, Peretz G, Yehuda YB. Psychological guidelines for a medical team debriefing after a stressful event. Mil Med. 2007;172(6):581-5.Knobler HY, Nachshoni T, Jaffe E, Peretz G, Yehuda YB. Psychological guidelines for a medical team debriefing after a stressful event. Mil Med. 2007;172(6):581-5.As the first wave of the COVID-19 pandemic subsides and plans for the next academic cycle begin, Internal Medicine residency program leadership should reevaluate their initial pandemic planning response. Ongoing adjustments with the potential of additional waves of disease or outbreaks should be considered with attention to the need for restructuring as new trainees who would require more oversight and support matriculate. Onboarding of new trainees may require virtual elements to avoid large group gatherings and include more rigorous training in proper PPE use . ProgramCOVID-19 has severely disrupted healthcare delivery systems around the world, and the impact of this disease remains far-reaching. In order to address the current pandemic and potential future crises, training programs need to be thoughtful about the effects on both their learners and the clinical environment in which their trainees practice. These 12 recommendations provide a framework for program directors as they consider the many facets of their training program that may be affected by a pandemic as well as ways in which current practices may be adapted. These tips are not exhaustive but are meant to serve as a basis for initial evaluation and programmatic improvement.•Training programs should develop an evidence-based, systematic approach as they consider how their particular program will need to adapt to a pandemic or similar crisis•Points to consider include inpatient and outpatient practices, provider safety, resuscitation practices, virtual education programming and resident wellbeing•It is important that programs reexamine their initial pandemic response and adjust practices as indicated•As we cross over into the new academic year during the current pandemic, programs should be developing plans to transition new trainees into the work force and devising plans how best to prepare current residents for the next phase in their careersCarleen Spitzer, MD is an Assistant Professor in the Division of Pulmonary and Critical Care Medicine and an assistant program director of the Internal Medicine Residency Program at The Ohio State University Wexner Medical Center.Jennifer Allen, MD is an Assistant Professor in the Division of Hospital Medicine and an associate program director of the Internal Medicine Residency Program at The Ohio State University Wexner Medical Center.Tejas Sinha, MD is one of the chief internal medicine residents at The Ohio State University Wexner Medical Center.Devin Haddad, MD one of the chief internal medicine residents at The Ohio State University Wexner Medical Center.Ellen Liu, MD is one of the chief internal medicine residents at The Ohio State University Wexner Medical Center.David Wininger, MD is the Internal Medicine Residency program director and an Associate Professor in the Division of Infectious Diseases, Department of Internal Medicine at the Ohio State University Wexner Medical Center.Lisa Kearns, MD, MS is an Assistant Professor in the Division of General Internal Medicine, program director for the Primary Care Track Program and associate program director of the Internal Medicine Residency Program at The Ohio State University Wexner Medical Center.Jared Moore, MD is an Associate Professor in the Division of General Internal Medicine and an associate program director for the Internal Medicine Residency Program.Allison Rossetti, MD is an Assistant Professor in the Divisions of Adult and Pediatric Hospital Medicine and assistant program director of the Internal Medicine and Pediatric Residency Program at The Ohio State University Wexner Medical Center and Nationwide Children’s Hospital. This review has been migrated. The reviewer awarded 4 stars out of 5 An interesting paper that joins the large number of other papers related to management of individuals and groups during the Covid-19pandemic. The group chosen here are internal medicine residents, a group not frequently spoken of. The tips represent a logical approach to care and safety of the residents and although a little US-centric, they are transferable to other forms of junior staff.I would hope now that these authors begin to evaluate their actions to see if these tips really are of value and also how they have implemented them.I would recommend this paper to all involved in resident training, particularly during this very difficult timeReviewer Expertise:NANo decision status is available This review has been migrated. The reviewer awarded 4 stars out of 5 Thank you; there are many useful ideas here about continuing to manage the experience of junior staff so that patient care is continued, education is preserved and everyone is kept as safe as possible. Although there is now an extensive literature on changes to UG teaching, especially assessment, there has been less on managing the inevitable conflicts which arise in situations where care givers are also trainees.Reviewer Expertise:NANo decision status is available This review has been migrated. The reviewer awarded 4 stars out of 5 Thank you for the article. There are several useful tips highlighted in this article especially in terms of well being of the residents. Moving forward perhaps just 2 pointers to possibly elaborate further 1) Possible suggestions to mitigate the issue of patient consent/ privacy to be part of telemedicine / e- learning 2) Quality of residents who graduate with these limitations during pandemic era towards becoming a specialist in the future.Reviewer Expertise:NANo decision status is available


Adolescent girls and young women in Uganda face numerous public health challenges including high HIV prevalence, teenage pregnancies, poor sexual and reproductive health rights, child marriage, and violence.This evidence review explores which interventions focusing on the empowerment of adolescent girls and young women to address these challenges are suitable for Ugandan policy.We reviewed the literature to identify experimental studies and systematic reviews of interventions which improve sexual and reproductive health outcomes and/or prevent violence in adolescent girls and young women in low- and middle-income countries (LMICs). Two authors independently reviewed the studies identified through a comprehensive search strategy and assessed their quality. From this evidence base, two policy options were explored in depth considering benefits, harms, equity impacts, and costs, given the Ugandan context.The screen yielded 47 studies, of which 12 remained after applying inclusion and exclusion criteria and relevance, applicability and quality assessment. Feasible policy options included: a vertical cash-incentive approach at a national or local level to support girls' attainment of education; and a horizontal integrated community approach focusing on skills and knowledge building. A combination of both is recommended for young female empowerment in Uganda, allowing for the full range of socio-cultural and economic drivers to be targeted.Research into the link between female empowerment and sexual and reproductive health outcomes is still in early development. This review contributes to evidence on this topic and outlines an approach that is potentially suitable for adoption across similar LMICs in Africa. There are an estimated 580 million adolescent girls worldwide, 88% of whom live in low-and-middle income countries (LMICs) where sexual and reproductive health (SRH) is a major issueth birthdaySocio-economic, structural and cultural determinants drive these issues. Young girls are more likely to drop out of school and marry at an early age. An estimated 40% of girls in Uganda marry before their 18Greater gender equality and female empowerment are associated with reduced risk of intimate partner violence, improved general health, fertility, and mortality outcomes, better access to education, and greater economic securityA number of initiatives aim to reduce the vulnerabilities of adolescent girls, focusing on how economic empowerment interventions such as waivers of school fees, cash transfers and microfinance schemes can allow vulnerable girls in LMICs to be less reliant on male partnersWe drew on Supporting the Use of Research Evidence (SURE) guides for evidence-based policy briefsA comprehensive literature search strategy was constructed to identify studies reporting on female empowerment interventions to improve SRH outcomes and prevent violence against adolescent girls and young women. Databases searched were: PubMed (2005–2019); Global Health (CABI) (2005–2019) and Cochrane (2005–2019). Details of search terms and the population, intervention, control, outcome (PICO) search strategy is provided in the Appendices .Experimental or quasi-experimental studies or systematic reviews (SR) that evaluated programmes reporting on female empowerment interventions to improve SRH outcomes and prevent violence against adolescent girls and young women were sought. Inclusion criteria were: published studies in English; interventions implemented in adolescent girls and young women (age 10–24 years) in LMICs; interventions focusing on empowerment approaches; and outcomes including SRH and/or preventing violence against women. Empowerment approaches included life skills and economic interventions at the national, household or individual level, as long as they were specifically targeted at adolescent girls and young women. SRH outcomes included those relating to sexual risk behaviour, marital status, pregnancy and births, and sexually transmitted infections. We excluded studies: with females of other age groups; that were non-gender specific; in high income countries; with interventions that focused on women's health issues without an empowerment approach; and focusing on non-health related development outcomes.One author conducted the initial screen of paper titles and abstracts. Two authors independently reviewed the retrieved full papers that met the inclusion criteria, resolving selection disagreements through discussion. Selected papers were assessed for applicability to the Ugandan context using a checklist adapted from SUPPORT Tools for evidence-informed health PolicymakingFrom this evidence base, we explored potential policy options according to a framework developed by Buffet et al.The literature search yielded 47 papers. On review of titles and abstracts, 27 papers were relevant based on inclusion criteria. The full text of these were assessed in detail for relevance, applicability and quality, after which a further 15 papers were rejected. Twelve studies were included in the final analysis  approaches can serve as mechanisms to disseminate knowledge and skills in low resource settingsAccessibility to both schools and community centres need consideration for both policy options. The Universal Primary Education PolicyFinancial and human resources must be considered to scale nationally. For example, the ELA was NGO-run and had very frequent interaction and high asset transfer amounts. It may be difficult to reasonably implement the intensity of the inputs at scale. However, the International Labour Organisation argues that basic social protection benefits are not unaffordable in LMICs in Sub-Saharan Africa, even though some international assistance would be necessary for a transitory periodInformation systems are also crucial to monitoring uptake and distribution of the cash-transfer component. Uganda launched a national Health policy and strategy 2017–2021 in May 2018 to strengthen digital infrastructure and eHealth capabilities.A strong social and cultural stigma around SRH still pervades in Uganda and is a key barrier to women seeking out key servicesPolitical will is crucial for successful implementation in Uganda, particularly cash-transfer programmes which require substantial financial input for national scaling. Beyond national legislation, the Ugandan Government has pledged improvements in SRH on the international stage by committing to the SDGs. They were one of the first African countries to develop their 2015/16–2019/20 National Development Plan in line with the SDGs and partnered with international organisations to try and achieve thisThis paper explores two policy options for implementation in Uganda: a cash-incentive approach; and an integrated multi-component approach with a focus on skills and knowledge building. Barriers and enablers at the recipient and provider levels, the system level and the social and political level were considered. The authors recommend interventions to be initiated before age 13 in girls to best target girls before they are found to typically leave school. Additionally, social and cultural factors need to be addressed, where strong community involvement including local training, skill-building and mentorship within the community enabling this. Resources are a major consideration and substantial government funding would be required for sustainability. However, as the majority of the cash-transfer programmes assessed in this review were funded by NGO grants, a range of funding sources should be considered in the LMIC context. Additionally, this paper's literature review demonstrates convincing evidence that initial investments would be outweighed by long-term economic benefits. The above policy options are aligned with current Ugandan policy, which explicitly prioritises and encourages gender equity and female empowerment, and with Uganda's SDG commitments.Limitations of this evidence review include the paucity of research in this area. Work to expand current primary research interventions into empowerment interventions effective for young women and girls in LMICs, as well as robust systematic reviews of these interventions, is strongly recommended. Furthermore, by limiting this review to interventions focusing only on adolescents and young women, interventions targeting older women were excluded, but may have been effective in younger groups. We also did not explore the important role of men in supporting female empowerment or of non-gender specific interventions, however, including these elements may make it difficult to specifically identify what is working. Further research into mixed-gender approaches to empower girls and breakdown cultural norms, particularly around SRH and IPV, is also recommended.


Chuang and Chen) to specific cell type MIC responses in immune cells , chondrocytes  and cancer cells .The cellular microenvironment is full of mechanical challenges ranging from shear and compressive stress to tension and substrate stiffness. Ion channels can sense all these mechanical stimuli directly through innate force sensing or through lipids and filaments, including cytoskeleton and extracellular matrix. Mechanical forces are therefore rapidly transformed in electrochemical signals through the activity of ion channels which in turn defines cellular physiology and fate. Mechanosensitive ion channels (MIC) are essential in controlling a variety of cellular processes such as transcription, differentiation, adhesion and migration, and their multifaceted consequences in pathophysiology: hearing, touch, neurotransmission, development, hemodynamics, inflammation, neurodegeneration, cardiovascular disease and oncogenesis. This Research Topic presents some recent advances on the molecular mechanisms of MIC activation and regulation as well as their effects on intracellular signaling and cellular responses. The Research Topic comprises four Review papers going from the mechanistic aspect of the MIC as a mediator of mechanical communication between the cell cytoskeleton with extracellular matrix in all cell types  and fluid  surroundings of the tumor microenvironment. Bera and others explain in the first place all these mechanical forces encountered by cancer cells at the primary tumor site as well as at the invasion sites. In a second part the authors describe how these physical forces act on MIC activity and in particular of Piezo1/2, TRPC1, TRPC5, TRPM2, TRPM4, TRPM7, TRPV2, and TRPV4 and affect cancer metastasis.This Research Topic of reviews nicely shows that understanding the pathophysiological importance of mechanosignaling and the role played by MICs therein offers the potential to design concepts of targeted “mechano-therapy”.


Children with special health care needs (SHCN) due to a chronic health condition perform more poorly at school compared to their classmates. There is still little knowledge on the causal pathways and which factors could be targeted by interventions. We, therefore, investigated school absenteeism in children with SHCN compared to their peers.This study was based on data from the German population-based prospective cohort study ikidS (German for: I will start school). Children with SHCN were identified by the Children with Special Health Care Needs screener that captures five consequences of physical or mental chronic health conditions: (1) use or need of prescription medication, (2) above average use or need of medical, mental health, or educational services, (3) functional limitations compared with others of the same age, (4) use or need of specialized therapies, and (5) treatment or counseling for emotional, behavioral, or developmental problems. School absenteeism was defined as days absent from school due to illness during first grade and was reported by classroom teachers. Associations between SHCN consequences and school absenteeism were investigated by negative binomial regression models. Effect estimates were adjusted for confounding variables identified by a causal framework and directed acyclic graphs.1,921 children  were included; of these, 14% had SHCN. Compared to their classmates, children with SHCN had more days absent . The effect was strongest among children with i) functional limitations, ii) treatment or counseling for emotional, behavioral, or developmental problems, and iii) those who experienced two or more SHCN consequences.Children with SHCN have higher school absenteeism, which could–at least partly–explain their poorer school performance and lower educational attainment. SHCN-specific targeted interventions may reduce the adverse effects of SHCN on educational outcomes in children. The number of children with special health care needs (SHCN) due to a chronic health condition has increased over the past decades , and theThe relationships between child health and educational outcomes and the potential mediating and moderating factors have been conceptualized in a theoretical framework by Suhrcke and de Paz Nieves . This frWithin this framework, school absenteeism plays a crucial role for several reasons: i) It may hamper a child’s ability to build relationships with classmates and keep it from participating in school activities that may stimulate their learning and development, ii) it is an important predictor for academic achievement , iii) itThere is substantial research showing that school absenteeism is negatively associated with students’ academic achievement in children without SHCN. For instance, Klein et al.  studied Most of the evidence, however, came from studies in North America, where children with mild to moderate SHCN usually attend regular schools without having the opportunity for supportive school health services as provided in special schools. For European countries such as Germany, where children with physical or mental disabilities, medical complexity and/or severe SHCN are commonly attending special schools with supportive school health services provided by trained nurses and other health professionals, the evidence is scarce. Due to this selection process prior to school entry, it is unclear, if children with SHCN who attend regular schools are still more likely to have poorer educational outcomes than their peers, and, therefore, may require support. In addition, most studies on the association between SHCN and educational outcomes used cross-sectional instead of longitudinal study designs , which mThe present study used data from the population-based prospective cohort study "ikidS". Details on the ikidS cohort have been published elsewhere , 10. In Approval was granted by the ethics committee of the regional medical association of Rhineland-Palatinate ), the regional supervisory school authority, and the state representative for data protection in Rhineland-Palatinate. Informed written consent was obtained from legal guardians of all children included in the study.Children who were eventually enrolled in an elementary school in 2015 were included in the present study. Children with mental disabilities or a recommendation for a special needs school were excluded.Children with SHCN were identified prior to school entry and at the end of first grade according to their needs and use of special health care or functional limitations by a German version of the Children with Special Health Care Needs screener filled out by parents . The scrThe outcome was defined as total days absent from school due to illness during first grade and was reported by the child’s classroom teacher at the end of first grade.A directed acyclic graph (DAG) for the association between chronic health condition and days absent from school was constructed to identify a minimally sufficient adjustment set . PotentiBesides the overall effect, we studied the independent associations of each of the five SHCN consequences on days absent. Therefore, a second DAG was constructed including the five SHCN consequences as independent variables and days absent as the dependent variable . This alDescriptive statistics were based on complete cases only. Distributions of continuous variables are presented as mean and standard deviation (SD) or median and interquartile range (IQR) as appropriate; results of categorical variables are reported as absolute and relative frequencies. Pairwise correlations between the five binary SHCN consequences were given as phi correlation coefficients.MASS [We estimated the effect of SHCN on days absent from school due to illness from a negative binomial regression model (R package MASS ) adjustemice [Missing values for SHCN status, confounding variables, and days absent from school due to illness during first grade were imputed 10 times using multivariate imputation by chained equations and 100 iterations (R package mice ) which imice . Only pomice . All anamice .n = 51), recommendation for a special needs school (n = 27), and mental disability (n = 4) ; reasons for exclusion were deferral from school entry ( (n = 4) . Childre (n = 4) .In total, 202 children  had SHCN either prior to school entry or at the end of first grade; of these, 43% had SHCN at both time points. Seventy-nine percent of children with SHCN had at least one medical diagnosis that might negatively affect school performance. The most frequent diagnoses were asthma (22%), attention-deficit hyperactivity disorder , and atopic dermatitis (16%) . CompareThe most frequent SHCN consequences were above average use or need of medical, mental health, or educational services and use or need of prescription medication (each 46% among children with SHCN), treatment or counseling for emotional, behavioral, or developmental problems (41%), use or need of specialized therapies (40%), and functional limitations compared with others of the same age (19%). Pairwise correlations (phi coefficient) were highest between above average use or need of medical, mental health, or educational services and each of the other consequences  and between use or need of specialized therapies and treatment or counseling for emotional, behavioral, or developmental problems (0.51) .About half of the children with SHCN experienced only one consequence (52% of children with SHCN), while the other half experienced more than one .Children with SHCN had slightly more days absent from school than children without SHCN (median (IQR) 5 (7) vs. 4 (5)). The distribution of days absent for these children was slightly shifted towards more days absent from school , Fig 2. The strongest association between individual SHCN consequences and days absent from school due to illness was found for functional limitations compared with others of the same age  and treatment or counseling for emotional, behavioral, or developmental problems  were negatively associated with achievement at the end of compulsory and postcompulsory schooling . The magand school performance.School absenteeism may therefore be a promising target for health-related interventions in children with SHCN. Generic interventions with specific measures for individual conditions aiming to reduce school absenteeism may potentially mitigate the negative effects of SHCN on educational outcomes. For example, a nurse-delivered asthma program to elementary schools led to a significant reduction in school absence and interrupted activities in children with asthma . The effMost studies on the association between health and educational outcomes have been conducted in the United States , 22, 23.without current SHCN were not identified and remained in the comparison group for analysis. Any remaining misclassification may not be important, since a previous study from the ikidS project suggested that a chronic health condition without actual SHCN is not related to poorer school performance [For the identification of affected children, we used a comprehensive consequences-based concept of chronic health conditions, the actual need for special health care as measured by the Children with Special Health Care Needs screener. This approach defines the presence of a relevant chronic condition through the parent-reported actual need or use of these services and perceived functional impairments. Thus, children with chronic health conditions but formance .In many federal states of Germany, most children with severe disabilities and medical complexity attend special schools; our sample of children attending regular public schools, therefore, included only children with mild to moderate physical, developmental, and mental health conditions, as well as children who are currently medically evaluated and have no definitive diagnosis. Thus, our findings can not be generalized to children with SHCN attending special schools.In our sample of children with SHCN, the majority of children had asthma or ADHD. Due to this heterogeneity, the effect on days absent from school reported in this study should be interpreted as the pooled effect of individual effects of the underlying conditions.In a sample from children attending regular schools without children with severe disabilities and medical complexity, children with mild to moderate SHCN may still have more school days absent compared to children without SHCN. This is of importance as regular schools–in contrast to special schools–are usually not equipped with school health services and affected children are not identified and supported.Our findings indicate issues with the allocation of children with SHCN to regular schools and the uptake and the effectiveness of existing medical care as well as educational support concepts for children with SHCN in regular schools. Our results also suggest that days absent should be monitored at school in particular in children with SHCN and reasons for the absence should be addressed.Existing school health services may be extended with measures tailored for individual health conditions with the goal to reduce school absenteeism. In countries, where school health services are not yet fully established (as in Germany), our results may be used to indicate the urgent need for such services, especially for children with SHCN.Finally, the fast growing body of evidence on school health interventions for children with SHCN should be evaluated regularly, and effective interventions should be identified, established in policies, and transferred to school health practice. Scoping reviews, implementation guidelines, and best practices would be in particular helpful to achieve those goals.S1 FigVariables in red indicate the minimally sufficient adjustment set. Paths in grey were blocked by the adjustment set. Abbreviations: Accid, accidents; AgeSchEntr, age at school entry; BMI, body mass index; Breastf, breastfeeding; CHCfam, chronic health condition in the family; DaysAbs, days absent from school; EducOrient, educational orientation; HealCarUtiliz, health care utilization; HospStay, hospital stay; Infect, infections; MH, mental health; MigrBackgr, migrant background; Multip, multiple at birth; Nutr, nutrition; PhysAct, physical activity; PreAcadSkills, pre-academic skills; SES, socio-economic status; SHCN, special health care needs; Sibl, siblings; SinglParFam, single-parent family; SocInt, social integration; and WorkTimMod, work time model.(TIF)Click here for additional data file.S2 FigAbbreviations: SHCN, special health care needs, and DAS, days absent from school.(TIF)Click here for additional data file.S3 Fig(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


Korean immigrants are among the fastest-growing ethnic minority groups and make up the fifth-largest Asian group in the United States. A better understanding of the work environment factors and its impact on Korean American nurse and primary care provider (PCP) burnout may guide the development of targeted strategies to help mitigate burnout and workplace stressors, which is critical for the retention of Korean American nurses and PCPs to promote better alignment of national demographic trends and meet patients’ preference for cultural congruence with their health care providers (HCPs). Although there is a growing number of studies on HCP burnout, a limited number of studies specifically focus on the experience of ethnic minority HCPs, particularly during the COVID-19 pandemic.In light of these gaps in literature, the aim of this study was to assess burnout among Korean American HCPs and to identify work conditions during a pandemic that may be associated with Korean American nurse and PCP burnout.A total of 184 Korean American HCPs  practicing in Southern California responded to a web-based survey between February and April 2021. The Maslach Burnout Inventory, Areas of Worklife Survey, and Pandemic Experience & Perceptions Survey were used to measure burnout and work environment factors during the pandemic. A multivariate linear regression analysis was used to assess work environment factors associated with the 3 subcategories of burnout.P<.001), lower resource availability (P=.04), and higher risk perception (P=.02) were associated with higher emotional exhaustion. Greater workload was also associated with higher depersonalization (P=.003), whereas a greater  community (P=.03) and higher risk perception (P=.006) were associated with higher personal accomplishment. For PCPs, greater workload and poor work-life balance were associated with higher emotional exhaustion  and depersonalization , whereas only reward was associated with personal accomplishment (P=.006).No significant differences were found in the level of burnout experienced by Korean American nurses and PCPs. For RNs, greater workload (Findings from this study underscore the importance of strategies to promote a healthy work environment across multiple levels that recognize demographic variation among Korean American RNs and PCPs, potentially influencing their burnout mitigation needs. A growing recognition of identity-informed burnout experiences across frontline Korean American RNs and PCPs argues for future explorations that capture nuance both across and within this and other ethnic minority nurse and PCP groups. By recognizing and capturing these variations, we may better support the creation of targeted, burnout-mitigating strategies for all. Even before the COVID-19 pandemic, 35% to 45% of nurses and 40% to 54% of physicians in the United States reported experiencing burnout -8. BurnoThe triple aim, which sought to enhance patient experience and improve population health while reducing costs, was expanded to the quadruple aim, recognizing the critical threat of burnout among health care providers (HCPs) . Most reIn 2020, approximately 24 million US residents self-identified as Asian. Of these 24 million US residents, approximately 1.9 million self-identified as Korean . Korean Studies across the health care literature have demonstrated that ethnic minority adults, including Korean American individuals, display a preference for providers from their background, those able to speak their native language, and who are familiar with historical challenges to accessing needed service . Given tDiscrimination, bullying, and incivility, especially in the workplace, undermine the culture of safety for both HCPs and patients alike. As such, in 2018, the Joint Commission has issued a Sentinel Event Alert on the physical and verbal violence against health care workers ,20. AddiThe Job Demands-Resources Theory suggests that job strain occurs when there is a mismatch between the demands placed on an individual and their ability to meet those demands -24. It cAlthough there is a growing number of studies on HCP burnout, a limited number of studies specifically focus on the experience of ethnic minority HCPs, particularly during the COVID-19 pandemic. A better understanding of the work environment factors that cause a mismatch between the demands placed on the HCPs and their ability to meet those demands leading to burnout may guide the development of targeted strategies to help mitigate HCP burnout. In light of these gaps in literature, the aim of this study was to assess burnout among Korean American HCPs and to identify work conditions during a pandemic that may be associated with Korean American nurse and primary care provider (PCP) burnout.Registered nurses (RNs), nurse practitioners (NPs), Doctors of Medicine (MDs), and physician assistants (PAs) who provide direct patient care in Southern California were eligible to participate. The participants were grouped into RNs or PCPs  based on their scope of practice. The decision to organize providers into these groups was informed by previous studies, which have shown that burnout levels are impacted by specific patient care tasks performed by different members of the health care team ,30. AlthRecruitment methods included the distribution of an informational flyer (in English) via email to approximately 196 RN and NP members of the Korean American Nurses Association of Southern California and approximately 4440 Korean American PCPs (MDs and PAs) within the Seoul Medical Group, Independent Practitioner Association; 200 members of the Korean American Medical Association of Southern California; and 40 members of the Korean American Graduate Medical Association. Recruitment fliers (in English) were also used as an advertisement through the social media platforms Facebook, Instagram, and KakaoTalk. Additional participants were referred to the study via word of mouth from participants of the study.Demographic information included participant gender, age (in years), education level, professional degree, tenure (years of work experience), work setting , and marital status.The Maslach Burnout Inventory–Human Services Survey (MBI-HSS) was found to be valid and reliable in previous studies evaluating employee burnout . The MBIThe Areas of Worklife Survey (AWS) is a survey created to assess employees’ perceptions of work setting qualities that play a role in whether they experience work engagement or burnout. These work setting qualities include workload (amount of work), control , reward , community , fairness (extent to which the organization has consistent and equitable rules for everyone), and values (what is important to the organization and to its members) . A mismaThe Pandemic Experience & Perceptions Survey (PEPS) assesses the perception of work settings specifically during pandemics, such as COVID-19, that impacts the way people work, with potential implications for employees’ health, well-being, and work engagement . The surData were collected on the web between February and April 2021, using the REDCap  system. Participants completed the electronic survey, which includes items from the demographic questionnaire, MBI-HSS, AWS, and PEPS. Each participant was assigned a unique record ID number automatically by REDCap upon the completion of the survey. The only identifiable data record linking the participant to the record ID number was their email address. The principal investigator reviewed all data collection forms on an ongoing basis for data completeness, duplication, and accuracy as well as protocol compliance.t tests were used for continuous variables and chi-square analyses were used for categorical variables. Bivariate Pearson correlation analysis was used to explore statistically significant factors associated with the 3 subcategories of burnout. All results with P<.05 were included in the multivariate linear regression analysis using the backward elimination method, to develop the most parsimonious final model to assess for factors associated with the 3 subcategories of burnout. All analysis was conducted using SPSS statistical software .Univariate analysis included descriptive statistics used to analyze participant demographics, levels of burnout, areas of worklife, and pandemic experience and perception. To assess for differences between RNs and PCPs, 2-tailed This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Cedars Sinai Medical Center . Informed consent was obtained from all individual participants included in the study.P=.85) or depersonalization (P=.52) between the 2 HCP groups, PCPs reported statistically significant higher levels of personal accomplishment (P=.03). There were also no significant differences in their perceptions of workload (P=.99), control (P=.33), community (P=.84), fairness (P=.30), value (P=.86), worklife (P=.10), and leadership (P=.08); however, significant differences were noted in reward (P<.001), resource availability (P=.03), and risk perception (P=.02).P<.05) were entered into the multivariate linear regression models.P<.001), lower resource availability (P=.04), and higher risk perception (P=.02) were associated with higher emotional exhaustion. Greater workload was also associated with higher depersonalization (P=.003), whereas a greater  community (P=.03) and higher risk perception (P=.006) were associated with higher personal accomplishment. For PCPs, greater workload (P<.001) and poor work-life balance (P=.005) were associated with higher emotional exhaustion  and depersonalization , whereas only reward was associated with personal accomplishment (P=.006).This study identified several aspects of the work environment associated with burnout for Korean American RNs and PCPs. As mentioned previously, the Job Demands-Resources Theory states that job demands such as heavy workload contribute to HCP burnout, whereas job resources, such as resource availability and social support, as well as recognition (reward) from peers and supervisors, contribute to professional well-being -24, whicHigher workload was associated with higher emotional exhaustion and depersonalization for RNs. With higher workloads come increased nurse encounters with patients and their caregivers and families, which may potentiate higher levels of emotional exhaustion and depersonalization. This may be particularly related to “emotional dirty work,” including diffusing charged patient interactions and other nuanced components of nursing tasks -37.Emotionally draining or contentious interactions with patients’ families changed for nursing staff in the era of COVID-19. Although many hospitals sought to limit the number of visitors, nurses had to find creative ways to support patient-family interactions through phone- or web-based platforms . AdditioFurthermore, many nurses themselves were dealing with increased patient assignments from their coworkers calling in sick or from dealing with childcare or other issues resulting from the pandemic. This may possibly provide additional context for how our participants interpreted the concept of “workload.”Higher risk perception and lower resource availability were also associated with higher emotional exhaustion, which has also been shown in other studies ,42. The Our findings also show that a greater sense of community is associated with higher personal accomplishment for Korean American RNs, which may help mitigate the negative effects of burnout. In a highly hierarchy-oriented culture, wherein someone’s role in the organization determines their “status,” established rules (often related to age) may prevent younger (or novice) employees from approaching older, high-status employees for guidance and support, and younger employees may be more susceptible to workplace bullying . DespiteAnother interesting finding from this study was the association between higher risk perception and higher personal accomplishment. The association between higher risk perception and higher emotion exhaustion is often a common finding across studies ,42; howeFor PCPS, higher workload and poor sense of worklife were associated with higher emotional exhaustion and depersonalization, whereas higher reward or recognition was associated with personal accomplishment. PCPs may feel particularly vulnerable to higher emotional exhaustion and depersonalization, reflecting a high volume of patient encounters associated with the heightened need for and concurrent deficit of independent practitioners during the COVID-19 pandemic . For proReward, which is also conceptualized as financial and social recognition for contributions on the job , was assSimilar to nurses, physicians have been recognized and hailed as health care “heroes” throughout the pandemic for their selfless acts and bravery. Although these PCPs certainly deserve much praise and attention, they deserve recognition in a way that is meaningful and enhances a sense of value to them. For instance, the “7 PM applause for health care heroes” initiative across the nation was a good way to show appreciation initially; however, it is not a sustainable strategy, nor does it address the underlying issue of HCP burnout. Furthermore, the term “health care heroes” masks the normalization of PCPs’ risk of exposure to the virus  and otheNursing organizations such as the Korean American Nurses Association of Southern California, Asian American Pacific Islander Nurse Association, and National Coalition of Ethnic Minority Nurse Associations may serve as a professional community to share knowledge and resources; reward, recognize, and celebrate accomplishments; and help to minimize structural, societal, and cultural barriers contributing to burnout. Education and training opportunities may include assertiveness or generational differences in the workplace training, professional or leadership development including navigating the organizational hierarchy, effective communication, and the importance of self-care. In addition, they may also promote nurturing mentoring relationships as well as fellowship and networking opportunities including in-person (while observing COVID-19 precautions as needed) or web-based social hours, hiking or nature walks, and peer support groups for Korean American nurses by Korean American nurses.Likewise, organizations such as the Korean American Medical Association of Southern California and Korean American Graduate Medical Association may serve as a professional community to help promote similar opportunities for Korean American PCPs. For instance, in a report by the American Medical Association on the experiences of ethnic minority physicians in the United States during the COVID-19 pandemic, Asian physicians reported that access to support and fellowship with others of similar demographic backgrounds would improve the sustainment of their well-being . AdditioMoreover, these professional organizations may collaborate with community partners to provide comprehensive HCP wellness programs  to help mitigate the adverse effects of burnout for Korean American HCPs. For instance, Korean American professional nursing and medical associations may collaborate with Korean community organizations such as the Korean Cultural Center, Los Angeles, to implement programs  for Korean American HCPs to promote overall well-being.Furthermore, a community website or repository where Korean American HCPs and professional organizations can collaborate with community partners to share timely and accurate health information would benefit both HCPs and the community alike. According to a recent systemic review, up to 28.8% of social media posts about COVID-19 could be classified as misinformation . Such inTargeted strategies for nurses and PCPs at the health care systems level, such as the distribution of fair workload and opportunities for all members of the health care team to practice at the top of their scope and being involved in decision-making opportunities, may improve a sense of control over their practice. Shared leadership councils, flexible work schedules, various nursing models, and the use of technology-based workers or assistants have been explored as potential strategies to promote nursing participation in decision-making processes, improve nursing workflow, and reduce workload.Although PPE and other resource shortages are currently not as critical as they were at the start of the COVID-19 pandemic, health care organizations must remain diligent and be prepared for whatever future catastrophes that they may face. Regular inventory checks of essential health care resources both within the health care organization and throughout the community are critical. Additionally, routine incident command system and emergency management training in collaboration with local ethnic communities may be helpful, especially in meeting the needs of culturally and linguistically diverse populations.There are several implications for future research. First, just as there is a critical need for culturally congruent care provided by HCPs with similar cultural backgrounds to the patients they care for, there is a need for more culturally congruent research to be conducted by ethnic minority researchers who share the same cultural background as their participants. Such researchers are more likely to understand the cultural context and nuance of the research topic. This can be particularly important when researching culturally sensitive topics, for instance, when the research involves Korean cultural practices or beliefs or making practical and impactful recommendations specific to Korean American HCPs.Along these lines, research focusing on ethnic minority groups should closely examine potential factors that impact health disparities and parse out the variations and nuances that exist within these groups. For instance, lumping all Asian American groups together—that is, combining the Korean American group with others from East, South, and Central Asia—may not only miss important subcultural differences but also mask meaningful differences in health risks among these groups, including mental health–related risk factors. Therefore, future studies on ethnic minority groups should consider the cultural and sociodemographic heterogeneity as well as variations in health risk factors that distinguish each subgroup before aggregating them into one group.Finally, more funding opportunities aimed at exploring identity-informed burnout experiences of HCPs and studies aimed at capturing nuances both across and within ethnic minority groups are needed. The COVID-19 pandemic has exasperated already high levels of burnout among HCPs around the globe. Supporting HCP well-being requires continuous investment in burnout research and information sharing to advance evidence-based solutions , contextThe study participants were recruited among Korean American nurses and PCPs practicing in Southern California; therefore, the findings from this study may not be generalizable to all nurses and PCPs. Additionally, the total study population could not be confirmed, especially as the participants were referred to the study via word of mouth from other participants. Consequently, the response rates could not be confirmed. Nonetheless, the methods applied and lessons learned from this study may guide further studies that apply more rigorous research methods to evaluate the work environment’s impact on burnout and the well-being of nurses and PCPs from various ethnic minority groups.Furthermore, the assessment of Korean American nurses’ and PCPs’ experience with discrimination, such as “Asian Hate,” during the pandemic and its impact on burnout was not within the scope of this study. Although we draw attention to the potential relationship between these factors among our study participants, further studies specifically assessing their experience with discrimination are needed to make direct correlations between nurse and PCP discrimination and burnout. Additional aspects of personal identity beyond ethnic/racial group, such as generation in the United States, language preference, and level of acculturation, among others, would allow for a more refined view of this experience among Korean American nurses and PCPs and should be considered in future iterations of this work.Three years into the start of the pandemic, the COVID-19 endemic seems more hopeful than the burnout endemic. Findings from this study underscore the importance of a multilevel nurse and PCP wellness program sponsored by professional organizations, communities, and the health care institutions in which these nurses and PCPs practice. Finally, a growing recognition of identity-informed burnout experiences across frontline Korean American nurses and PCPs argues for future explorations that capture nuance both across and within this and other ethnic minority nurse and PCP groups. By recognizing and capturing these variations, we may better support the creation of targeted, burnout-mitigating strategies for all.


Ultrasound (US) is recognized as a practical and safe form of medical imaging that utilizes ultrasound waves to develop images for diagnostic and procedural purposes. The clinical use of US has dramatically increased over recent years, secondary to the ease of use, portability, and functionality of US. The success of point-of-care ultrasound implementation into residency curricula has further underscored the importance of US education and its potential for use earlier in medical instruction. Osteopathic medical education places a significant emphasis on anatomy, thus a scoping review of the literature regarding the use of US in osteopathic preclinical years is warranted.The goal of this scoping study is to assess the current literature regarding the implementation and benefit of US instruction in preclinical osteopathic medical curricula. Four resources were utilized for the review, including PubMed, Google Scholar, JOM (formerly JAOA), and AMED, each with contiguous criteria for applicable literature. The searches were performed before the end of January 2023. Inclusion criteria for researched literature focused on osteopathic preclinical utilization of US technologies. Articles were subsequently evaluated using thematic and contextual analysis.Of the 2,968 articles evaluated, 22 articles met the inclusion criteria. There were several themes associated with the implementation of US within osteopathic curricula, including positive student perceptions of the modality, improved learning outcomes, and adaptations of US instruction into anatomical sciences courses.There is a need for continued research regarding US implementation in preclinical osteopathic medical school education, including within anatomical sciences. A minority of osteopathic schools have published details regarding how US has been applied in their curriculum. Ultrasound (US) is considered a practical and safe form of medical tomography that utilizes ultrasound sound waves to generate anatomic images for diagnostic and procedural purposes. US has been utilized by physicians for the last five decades and has rapidly improved in affordability, quality, and functionality . The utiIn tandem with enhanced student learning, introducing ultrasonography has proven beneficial for many medical specialties, including anesthesia, cardiology, emergency medicine, surgery and associated subspecialties, and internal medicine . As an oSearch protocolThe comprehensive assessment of available literature for this project was initiated in May 2021 and concluded in January 2023. MS, RP, DD, SW, and TM participated in the search. All authors assisted with reviewing the articles to ensure the inclusion criteria were met. Four resources were utilized for the scoping review, namely, PubMed, Google Scholar, The Journal of Osteopathic Medicine (JOM) formerly the Journal of the American Osteopathic Association (JAOA), and the Allied and Complementary Medicine Database (AMED). The following keywords were searched in each: “Osteopathic undergraduate ultrasound,” “Osteopathic ‘medical education’ ultrasound,” “Ultrasound undergraduate osteopathic education,” “Ultrasound osteopathic education,” “Osteopathic medical school ultrasound education,” and “ultrasound preclinical osteopathic.” With each keyword, the number of articles that populated was recorded, along with the number of articles that fit the inclusion criteria and any duplicates. There was no limit to the publication date of the articles as the prevalence of US technology in medical education was considered negligible prior to 20 years ago. A master list using an Excel Spreadsheet (Microsoft) was created and used to track articles that fit into the inclusion criteria to ensure there were no duplicates in the data, as seen in Figure Inclusion and exclusion criteriaThe inclusion criteria consisted of the following: educational research involving preclinical curricula, practices influencing the execution of osteopathic curricula, original articles with no duplicates, an article that was not a literature review, and research completed at an osteopathic institution. Exclusion criteria consisted of articles that were not in English/nor translated, incomplete articles, or articles not pertaining to US training of preclinical medical students. To avoid narratives, case studies, anecdotes, and small sample sizes, we also excluded publications with either a cohort size smaller than five people or an unpublished cohort size.Google Scholar searches amassed more results than we could reliably assess. For example, one search contained more than 16,000 results. After concluding three searches of several hundred results, we determined the following procedure was acceptable. We arranged the search list according to relevance and considered results until at least 40 consecutive results were irrelevant to our search.The aforementioned master list was used to verify at least two members of the research team reviewed each article and ensured all inclusion/exclusion criteria were properly applied. Each author added their initials to the article they reviewed. When two reviewers completed their assessment and agreed, the article was either included or excluded from the study. When there was a disagreement, an additional reviewer finalized the decision. Articles that met all the inclusion criteria were compiled into a table to summarize the results.Unpublished articles and solitary abstractsFor the project, an unpublished solitary abstract and several poster presentations were identified. These entities were labeled as “gray literature” in the article master list. The New York Institute of Technology College of Osteopathic Medicine (NYIT-COM) literature titled “The effect of integrating ultrasound imaging into osteopathic medical student palpation training” was an example of “gray literature” utilized in this review. This was included because it focused on implementing US into a specific curriculum as an introduction to US. Upon final review in preparation for publication, this “gray literature” poster had been converted to a publication supporting similar conclusions regarding the incorporation of ultrasonography into undergraduate preclinical osteopathic curriculums . We deteLiterature searchAn electronic search of the previously cited resources  and hand-searching resulted in 2,967 citations. After the manual removal of 97 duplicates, 2,870 citations remained to be screened Figure . The 2,8Ultrasound in osteopathic education among eligible studiesOf the accredited osteopathic medical schools with US in their curricula, the following nine educational institutions were responsible for the articles meeting the eligibility criteria: Kirksville College of Osteopathic Medicine (ATSU-KCOM), Arizona College of Osteopathic Medicine (AZCOM), Lake Erie College of Osteopathic Medicine Bradenton campus (LECOM-Bradenton), New York Institute of Technology College of Osteopathic Medicine (NYIT-COM), Rocky Vista University College of Osteopathic Medicine (RVU-COM), Texas College of Osteopathic Medicine (TCOM), Touro University College of Osteopathic Medicine (TUCOM), Edward Via College of Osteopathic Medicine (VCOM), and West Virginia School of Osteopathic Medicine (WVSOM).The osteopathic medical institutions meeting the inclusion criteria of this review delivered their US curriculum in a variety of ways to their students. The integration of US into curricula occurred in many forms such as assignments, clinical courses, laboratories, examinations, application-based clinics, video modules, workshops, expert training, and peer-assisted learning. Each medical school covered a wide variety of topics and structures, as shown in Table In the review of the literature, there were several positive themes within the implementation of US inside of osteopathic curricula. There was also a myriad of unknowns that may permit broader research with regard to the pedagogical improvement of US instruction within these institutions.Using the previously described eligibility criteria, our review revealed only 22 eligible sources out of the original 2,968 citations discovered. This indicates that most available literature was either beyond the scope of the study or was not focused enough for generalizable insights into the implementation of US on students’ performance in osteopathic preclinical medical education. For example, the ATSU article from Petty et al.  directlyOnly 10 out of 44 osteopathic institutions were shown within the literature to be actively measuring the impact of US instruction during the preclinical years . TheRegardless of potential barriers, there is a growing opportunity for the expansion of US education in osteopathic undergraduate medical curricula. Analysis of this small body of literature indicates a positive perception by students who engage in US integrated curriculum ,19. It wOverall, our review of the literature identified the need for further study regarding the use of US in preclinical course work as well as several introductory themes concerning US implementation into undergraduate preclinical osteopathic education. These themes included potential barriers to adopting the technology as well as instructional perceptions of its use in preclinical courses, such as anatomy or OMM. To increase the benefits of medical education, it may be necessary to include US in the anatomy curricula of undergraduate and graduate medical students. While there is still a great deal of exploration to be done within osteopathic institutions for the adoption of US in preclinical curricula, the perceived benefit for students seems to be high within current publications.


Background: Whiplash is associated with a wide variety of clinical manifestations, including headache, neck pain, cervical rigidity, shoulder and back pain, paresthesia, vertigo, and temporomandibular disorders (TMDs). Previous studies reported that TMDs are more common in individuals with chronic whiplash-associated disorders (WAD) than in the general population; however, the pathophysiology and mechanism of this relationship are still not well understood. Methods: A PubMed and Ovid EMBASE review was performed to identify all studies addressing the trauma related cause and effect relationship between WAD and TMDs from January 2003 to March 2023. Results: After screening for eligibility and inclusion criteria, a total of 16 articles met the selection criteria. The various included studies discussed different aspects of the association between WDA and TMDs, including changes in the coordination and amplitude of jaw opening, the severity of the associated symptoms/signs in cases of WAD, the degree of fatigue and psychological stress, difficulty in feeding, cervical and myofascial pain, changes in the MRI signal at various muscle points, muscle tenderness, and quality of life. Conclusions: In this review, we summarized the clinical evidence of any trauma related cause and effect relationship between whiplash and TMDs. An accurate screening of the previous literature showed that, in conclusion, the relationship between whiplash and TMDs is still unclear. Temporomandibular disorders (TMDs) refer to a group of conditions involving the orofacial region, divided into those affecting the masticatory muscles and those affecting the temporomandibular joint (TMJ) . WhiplasWAD is the term given to the collection of symptoms affecting the neck that are triggered by an accident with an acceleration–deceleration mechanism such as a motor vehicle accident . The incTo date, almost all hypotheses regarding the mechanism of rearend-impact-induced injury are based on kinematics . It seemMale and female muscle activity is affected by hormones . The actWhiplash is considered by scholars to be a traumatic event that adversely affects the patient’s posture, which not only alternately and antithetically displaces the cranio-cervical and trunk structures damaging the osteo-arthro-muscular district, but also results in a disordered displacement of abdominal body fluids . The bodThe aim of this review is to investigate if there are any trauma related cause and effect relationship between WADs and TMDs to add a new contribution to the literature.A PubMed and Ovid EMBASE review was performed to identify all studies addressing the trauma related cause and effect relationship of whiplash following cervical spine trauma with a temporomandibular joint clinical disorder. The following search terms were used from January 2003 to March 2023: whiplash OR whiplash injury AND temporomandibular disorder OR TMD OR TMJ OR temporomandibular joint disorders . Before A total of 56 articles, including those listed in the references of the retrieved studies, were found originally. We then excluded the following items: all publications not dealing with whiplash and TMDs; all studies different from original articles ; all preclinical studies; non-English written papers; and any other publication that did not comply with the goal of the present review. A total of 111 records were initially identified in the literature search, using Pubmed, Ovid, EMBASE, and Scopus databases, of which 55 were duplicates. After screening for eligibility and inclusion criteria, a total of 16 articles met the selection criteria ,35,36,37The majority of publications were case–control studies (n = 11), followed by comparative studies (n = 3), observational prospective studies (n = 1), and retrospectives studies (n = 1). All studies included were rated as level 4 or 5 evidence for clinical research as detailed in the Oxford Centre for Evidence-Based Medicine 2011 guidelines. A total of 2779 patients with or without WAD and TMDs were included. The various included studies discussed different aspects of the association between WDA and TMDs, including changes in the coordination and amplitude of jaw opening , the sevThe research diagnostic criteria for TMDs were introduced by Dworkin and LeResche in 1992 , who proOne of the first studies that investigated the trauma related cause and effect relationship between whiplash and TMDs investigated in a cohort of 25 individuals with WAD the presence of any limitations in jaw function and found a decreased amplitude and a change in temporal coordination between the movements of the mandible and the head–neck complex . Joint nHäggman-Henrikson et al.  conducteSimilar results were presented by Salé et al.  who condFurthermore, Grönqvist et al.  showed tLee and colleagues  conducteBal et al.  conducteCorsalini and colleagues  describeIn addition to analyzing the relationships between WDA, TMDs, and the possibility of involvement of the auditory system ,60,61,62Another alternative capable of assisting the management of WAD symptoms, particularly headaches, has proven to be the administration of Botulinum Toxin (TB) ,65. In pProspective research on whiplash populations should give a comparison with controls and provide a complete picture of the key factors impacting TMDs. The use of MRI, joint blocks, or injections, standardized, valid, and reliable clinical examinations, and appropriate outcome measurements could be used to identify these variables. Other findings that have been linked to whiplash and TMDs in studies should be considered as potential variables or descriptors to be defined in whiplash and TMDs populations. Examples include balance and postural abnormalities, shoulder–neck headaches, stress and psychosocial factors, parafunctional and adaptive habits, centrally mediated pain factors, and others ,71,72.Although this article used general inclusion/exclusion criteria, it lacked important criteria with a flowchart demonstrating the steps of exclusion based on the identification of studies included with specific research designs such as randomized control trials/case-control studies/cohort studies and identification of studies with specific statistical approaches and sample size. Other limitations include the lack of quality scoring and formal blinded appraisal of studies reviewed. In this review, we summarized the clinical evidence of any trauma related cause and effect relationship between whiplash and TMDs. An accurate screening of the previous literature showed that a true relationship between WADs and TMDs is still unclear. Although an association is most likely, it is unknown whether its strength is clinically significant. Further studies are needed to elucidate more the mechanisms of this relationship in order to improve the clinical and surgical treatment of these diseases.