BACKGROUND The stigma of obesity is a common and overt social bias. Negative attitudes and derogatory humor about overweight/obese individuals are commonplace among health care providers and medical students. As such, medical school may be particularly threatening for students who are overweight or obese. OBJECTIVE The purpose of our study was to assess the frequency that obese/overweight students report being stigmatized, the degree to which stigma is internalized, and the impact of these factors on their well-being. DESIGN We performed cross-sectional analysis of data from the Medical Student Cognitive Habits and Growth Evaluation Study (CHANGES) survey. PARTICIPANTS A total of 4,687 first-year medical students (1,146 overweight/obese) from a stratified random sample of 49 medical schools participated in the study. MAIN MEASURES Implicit and explicit self-stigma were measured with the Implicit Association Test and Anti-Fat Attitudes Questionnaire. Overall health, anxiety, depression, fatigue, self-esteem, sense of mastery, social support, loneliness, and use of alcohol/drugs to cope with stress were measured using previously validated scales. KEY RESULTS Among obese and overweight students, perceived stigma was associated with each measured component of well-being, including anxiety (beta coefficient [b] = 0.18; standard error [SE] = 0.03; p < 0.001) and depression (b = 0.20; SE = 0.03; p < 0.001). Among the subscales of the explicit self-stigma measure, dislike of obese people was associated with several factors, including depression (b = 0.07; SE =  .01; p < 0.001), a lower sense of mastery (b = -0.10; SE = 0.02; p < 0.001), and greater likelihood of using drugs or alcohol to cope with stress (b =  .05; SE = 0.01; p < 0.001). Fear of becoming fat was associated with each measured component of well-being, including lower body esteem (b = -0.25; SE = 0.01; p < 0.001) and less social support (b = -0.06; SE = 0.01; p < 0.001). Implicit self-stigma was not consistently associated with well-being factors. Compared to normal-weight/underweight peers, overweight/obese medical students had worse overall health (b = -0.33; SE = 0.03; p < 0.001) and body esteem (b = -0.70; SE = 0.02; p < 0.001), and overweight/obese female students reported less social support (b = -0.12; SE = 0.03; p < 0.001) and more loneliness (b = 0.22; SE = 0.04; p < 0.001). CONCLUSIONS Perceived and internalized weight stigma may contribute to worse well-being among overweight/obese medical students.

OBJECTIVE Physician knowledge of the complex contributors to obesity varies. We do not know whether today's medical students are graduating with deep understanding of the causes of obesity. Our objective was to assess beliefs about causes of obesity in a national sample of 4th year medical students. METHOD We randomly selected 2000 4th year students from a random sample of 50 U.S. medical schools and asked them to rate the importance of several factors as causes of obesity. Of those invited, 1244 (62%) responded. We conducted latent class analysis to identify groups with similar response patterns. RESULTS Most students demonstrated knowledge that obesity has multiple contributors. Students fell into 1 of 4 classes: (1) more likely to endorse all contributors (28%), (2) more likely to endorse physiological contributors (27%), (3) more likely to endorse behavioral or social contributors (24%), and (4) unlikely to endorse contributors outside of overeating and physical activity (22%). CONCLUSION Though students were generally aware of multiple causes, there were 4 distinct patterns of beliefs, with implications for patient care. PRACTICE IMPLICATIONS Targeted interventions may help to improve depth of knowledge about the causes of obesity and lead to more effective care for obese patients.

BACKGROUND Physician implicit (unconscious, automatic) bias has been shown to contribute to racial disparities in medical care. The impact of medical education on implicit racial bias is unknown. OBJECTIVE To examine the association between change in student implicit racial bias towards African Americans and student reports on their experiences with 1) formal curricula related to disparities in health and health care, cultural competence, and/or minority health; 2) informal curricula including racial climate and role model behavior; and 3) the amount and favorability of interracial contact during school. DESIGN Prospective observational study involving Web-based questionnaires administered during first (2010) and last (2014) semesters of medical school. PARTICIPANTS A total of 3547 students from a stratified random sample of 49 U.S. medical schools. MAIN OUTCOME(S) AND MEASURE(S) Change in implicit racial attitudes as assessed by the Black-White Implicit Association Test administered during the first semester and again during the last semester of medical school. KEY RESULTS In multivariable modeling, having completed the Black-White Implicit Association Test during medical school remained a statistically significant predictor of decreased implicit racial bias (-5.34, p ≤ 0.001: mixed effects regression with random intercept across schools). Students' self-assessed skills regarding providing care to African American patients had a borderline association with decreased implicit racial bias (-2.18, p = 0.056). Having heard negative comments from attending physicians or residents about African American patients (3.17, p = 0.026) and having had unfavorable vs. very favorable contact with African American physicians (18.79, p = 0.003) were statistically significant predictors of increased implicit racial bias. CONCLUSIONS Medical school experiences in all three domains were independently associated with change in student implicit racial attitudes. These findings are notable given that even small differences in implicit racial attitudes have been shown to affect behavior and that implicit attitudes are developed over a long period of repeated exposure and are difficult to change.

PURPOSE Research is lacking on psychological distress and disorder among sexual minority medical students (students who identify as nonheterosexual). If left unaddressed, distress may result in academic and professional difficulties and undermine workforce diversity goals. The authors compared depression, anxiety, and self-rated health among sexual minority and heterosexual medical students. METHOD This study included 4,673 first-year students who self-reported sexual orientation in the fall 2010 baseline survey of the Medical Student Cognitive Habits and Growth Evaluation Study, a national longitudinal cohort study. The authors used items from published scales to measure depression, anxiety, self-rated health, and social stressors. They conducted bivariate and multivariate analyses to estimate the association between sexual identity and depression, anxiety, and self-rated health. RESULTS Of 4,673 students, 232 (5.0%) identified as a sexual minority. Compared with heterosexual students, after adjusting for relevant covariates, sexual minority students had greater risk of depressive symptoms (adjusted relative risk [ARR] = 1.59 [95% confidence interval, 1.24-2.04]), anxiety symptoms (ARR = 1.64 [1.08-2.49]), and low self-rated health (ARR = 1.77 [1.15-2.60]). Sexual minority students were more likely to report social stressors, including harassment (22.7% versus 12.7%, P < .001) and isolation (53.7% versus 42.8%, P = .001). Exposure to social stressors attenuated but did not eliminate the observed associations between minority sexual identity and mental and self-reported health measures. CONCLUSIONS First-year sexual minority students experience significantly greater risk of depression, anxiety, and low self-rated health than heterosexual students. Targeted interventions are needed to improve mental health and well-being.

OBJECTIVE To determine whether attitudes toward patient-centered care differed by socio-demographic characteristics (race, gender, socioeconomic status) among a cohort of 3191 first year Black and White medical students attending a stratified random sample of US medical schools. METHODS This study used baseline data from Medical Student CHANGES, a large national longitudinal cohort study of medical students. Multiple logistic regression was used to assess the association of race, gender and SES with attitudes toward patient-centered care. RESULTS Female gender and low SES were significant predictors of positive attitudes toward patient-centered care. Age was also a significant predictor of positive attitudes toward patient-centered care such that students older than the average age of US medical students had more positive attitudes. Black versus white race was not associated with attitudes toward patient-centered care. CONCLUSIONS New medical students' attitudes toward patient-centered care may shape their response to curricula and the quality and style of care that they provide as physicians. Some students may be predisposed to attitudes that lead to both greater receptivity to curricula and the provision of higher-quality, more patient-centered care. PRACTICE IMPLICATIONS Medical school curricula with targeted messages about the benefits and value of patient-centered care, framed in ways that are consistent with the beliefs and world-view of medical students and the recruitment of a socioeconomically diverse sample of students into medical schools are vital for improved care.

Implications for practice and research: Healthcare providers from different fields may respond differently to patients with pain. On average, nurses rated pain intensity higher than physicians and were more likely to prescribe opioids. Patient demographic characteristics may influence nurses' and physicians' perceptions of pain intensity and decisions to treat pain with opioid analgesics. This study must be replicated with a more robust study design before findings can be translated into recommendations for intervention.

PROBLEM Sleep and mood represent two important malleable opportunities for adolescent health. This study investigated the sleep-mood relationship in adolescent girls. METHODS Short-term, longitudinal design. Latina adolescents (N = 19, mean age 15) completed ecological momentary assessments on sleep (perceived quality, self-report quantity) and mood (negative affect, positive affect, and positivity ratio). FINDINGS Adolescents sent 1,598 texts on sleep and mood. Bidirectional sleep-mood relationships were in expected directions; negative affect and the positivity ratio affect predicted adolescents' sleep quality. CONCLUSIONS Interventions should encourage sleep-mood relationship awareness, and further research should identify significant differences to inform tailored interventions with adolescents.

BACKGROUND Adolescent females send and receive more text messages than any others, with an average of 4050 texts a month. Despite this technological inroad among adolescents, few researchers are utilizing text messaging technology to collect real time, contextualized data. Temporal variables (ie, mood) collected regularly over a period of time could yield useful insights, particularly for evaluating health intervention outcomes. Use of text messaging technology has multiple benefits, including capacity of researchers to immediately act in response to texted information. OBJECTIVE The objective of our study was to custom build a short messaging service (SMS) or text messaging assessment delivery system for use with adolescents. The Youth Ecological Momentary Assessment System (YEMAS) was developed to collect automated texted reports of daily activities, behaviors, and attitudes among adolescents, and to examine the feasibility of YEMAS. This system was created to collect and transfer real time data about individual- and social-level factors that influence physical, mental, emotional, and social well-being. METHODS YEMAS is a custom designed system that interfaces with a cloud-based communication system to automate scheduled delivery of survey questions via text messaging; we designed this university-based system to meet data security and management standards. This was a two-phase study that included development of YEMAS and a feasibility pilot with Latino adolescent females. Relative homogeneity of participants was desired for the feasibility pilot study; adolescent Latina youth were sought because they represent the largest and fastest growing ethnic minority group in the United States. Females were targeted because they demonstrate the highest rate of text messaging and were expected to be interested in participating. Phase I involved development of YEMAS and Phase II involved piloting of the system with Latina adolescents. Girls were eligible to participate if they were attending one of the participating high schools and self-identified as Latina. We contacted 96 adolescents; of these, 24 returned written parental consent forms, completed assent processes, and enrolled in the study. RESULTS YEMAS was collaboratively developed and implemented. Feasibility was established with Latina adolescents (N=24), who responded to four surveys daily for two two-week periods (four weeks total). Each survey had between 12 and 17 questions, with responses including yes/no, Likert scale, and open-ended options. Retention and compliance rates were high, with nearly 18,000 texts provided by the girls over the course of the pilot period. CONCLUSIONS Pilot results support the feasibility and value of YEMAS, an automated SMS-based text messaging data collection system positioned within a secure university environment. This approach capitalizes on immediate data transfer protocols and enables the documentation of participants' thoughts, feelings, and behaviors in real time. Data are collected using mobile devices that are familiar to participants and nearly ubiquitous in developed countries.

OBJECTIVE Medical school curricula intended to promote empathy varies widely. Even the most effective curricula leave a significant group of students untouched. Pre-existing student factors influence their response to learning experiences. We examined the individual predictors of first semester medical students' attitudes toward the value of physician empathy in clinical encounters. METHODS First year students (n=4732) attending a stratified random sample of 49 US medical schools completed an online questionnaire that included measures of dispositional characteristics, attitudes and beliefs, self-concept and well-being. RESULTS Discomfort with uncertainty, close-mindedness, dispositional empathy, elitism, medical authoritarianism, egalitarianism, self-concept and well-being all independently predicted first year medical students' attitudes toward the benefit of physician empathy in clinical encounters. CONCLUSION Students vary on their attitude toward the value of physician empathy when they start medical school. The individual factors that predict their attitudes toward empathy may also influence their response to curricula promoting empathic care. PRACTICE IMPLICATIONS Curricula in medical school promoting empathic care may be more universally effective if students' preexisting attitudes are taken into account. Messages about the importance of physician empathy may need to be framed in ways that are consistent with the beliefs and prior world-views of medical students.

OBJECTIVE To examine the magnitude of explicit and implicit weight biases compared to biases against other groups; and identify student factors predicting bias in a large national sample of medical students. METHODS A web-based survey was completed by 4,732 1st year medical students from 49 medical schools as part of a longitudinal study of medical education. The survey included a validated measure of implicit weight bias, the implicit association test, and 2 measures of explicit bias: a feeling thermometer and the anti-fat attitudes test. RESULTS A majority of students exhibited implicit (74%) and explicit (67%) weight bias. Implicit weight bias scores were comparable to reported bias against racial minorities. Explicit attitudes were more negative toward obese people than toward racial minorities, gays, lesbians, and poor people. In multivariate regression models, implicit and explicit weight bias was predicted by lower BMI, male sex, and non-Black race. Either implicit or explicit bias was also predicted by age, SES, country of birth, and specialty choice. CONCLUSIONS Implicit and explicit weight bias is common among 1st year medical students, and varies across student factors. Future research should assess implications of biases and test interventions to reduce their impact.

OBJECTIVES We examined differences in self-reported mental health (SRMH) between US-born and Somalia-born Black Americans compared with White Americans. We tested how SRMH was affected by stigma toward seeing a mental health provider, discrimination in the health care setting, or symptoms of depression. METHODS Data were from a 2008 survey of adults in Minnesota and were limited to US-born and Somalia-born Black and White Americans (n = 938). RESULTS Somalia-born adults were more likely to report better SRMH than either US-born Black or White Americans. They also reported lower levels of discrimination (18.6%) than US-born Black Americans (33.4%), higher levels of stigma (23.6% vs 4.7%), and lower levels of depressive symptoms (9.1% vs 31.6%). Controlling for stigma, discrimination, and symptomatology, Somalia-born Black Americans reported better SRMH than White and Black Americans (odds ratio = 4.76). CONCLUSIONS Mental health programming and health care providers who focus on Black Americans' mental health might be missing important sources of heterogeneity. It is essential to consider the role of race and ethnicity, but also of nativity, in mental health policy and programming.

INTRODUCTION Breastfeeding initiation rates in the United States have risen in recent years. However, there are notable disparities by socioeconomic status and race/ethnicity. Previous research has suggested that care from a doula (a trained professional who provides nonmedical support during the perinatal period) may increase breastfeeding initiation. The goal of this analysis was to study whether doula support may be associated with breastfeeding initiation among low-income, diverse women. METHODS We compared breastfeeding initiation rates (means and 95% confidence intervals) for 1069 women who received doula care from Everyday Miracles, a Minnesota-based organization that employs a diverse group of certified doulas, to a state-based sample of women with Medicaid coverage who gave birth in 2009 or 2010 and participated in the Minnesota Pregnancy Risk Assessment Monitoring System survey (weighted n = 51,721). RESULTS Women who had doula-supported births had near-universal breastfeeding initiation (97.9%), compared with 80.8% of the general Medicaid population. Among African American women, 92.7% of those with doula support initiated breastfeeding, compared with 70.3% of the general Medicaid population. DISCUSSION These results suggest that access to culturally appropriate doula care may facilitate higher rates of breastfeeding initiation. When supported in their nonmedical needs by birth doulas, the diverse, low-income patients of midwives and other maternity care providers may have a greater likelihood of initiating breastfeeding and experiencing the maternal and infant health benefits associated with breastfeeding.

OBJECTIVES We compared childbirth-related outcomes for Medicaid recipients who received prenatal education and childbirth support from trained doulas with outcomes from a national sample of similar women and estimated potential cost savings. METHODS We calculated descriptive statistics for Medicaid-funded births nationally (from the 2009 Nationwide Inpatient Sample; n = 279,008) and births supported by doula care (n = 1079) in Minneapolis, Minnesota, in 2010 to 2012; used multivariate regression to estimate impacts of doula care; and modeled potential cost savings associated with reductions in cesarean delivery for doula-supported births. RESULTS The cesarean rate was 22.3% among doula-supported births and 31.5% among Medicaid beneficiaries nationally. The corresponding preterm birth rates were 6.1% and 7.3%, respectively. After control for clinical and sociodemographic factors, odds of cesarean delivery were 40.9% lower for doula-supported births (adjusted odds ratio = 0.59; P < .001). Potential cost savings to Medicaid programs associated with such cesarean rate reductions are substantial but depend on states' reimbursement rates, birth volume, and current cesarean rates. CONCLUSIONS State Medicaid programs should consider offering coverage for birth doulas to realize potential cost savings associated with reduced cesarean rates.

This study sought to understand the cost, quality of, and access to health care for the insured population in the context of spillover effects resulting from community-level uninsurance. We examined the health care access, quality, and cost experienced by insured Latina mothers in two communities, Minneapolis, Minnesota and McAllen, Texas. These communities differ substantially by the size of the local population without health insurance coverage. Four focus groups were conducted with insured Latina mothers who were caring for at least one child in their household. Eleven and thirteen mothers participated in each community, respectively. The experiences of the insured population in McAllen were substantially different from the experiences of the insured population in Minneapolis. The perceptions of health care quality and access by insured Latina mothers were substantially lower in McAllen while out-of-pocket costs were perceived to be higher in Minneapolis. Our study provides key insights about the US health care system and the role that the relative size of the local uninsured population may have in impacting the health care experiences of the insured. Health insurance coverage rates are expected to increase substantially across US communities within the next few years but local health care system challenges related to cost, quality, and access will remain for both the insured and the uninsured.

OBJECTIVES We examined the health care access, quality, and cost experienced by uninsured Latino mothers in two communities in Minnesota and Texas. These communities differ substantially by the size of the local population without health insurance coverage. METHODS Four focus groups were conducted with uninsured Latino mothers who were caring for at least one child in their household. Seventeen mothers participated in each community. All focus groups were conducted by the same trained staff from a non-profit, community-based research organization. RESULTS Uninsured Latino mothers in Minnesota rated the quality of health care services in their community to be much higher than their Texas counterparts, but were more likely to emphasize the high costs of care and health insurance coverage. Participants in Texas also described having to go to Mexico to obtain health care services. CONCLUSIONS Policies making provision for health care services to the uninsured are likely to be more effective when they take into account the context or composition of each specific local health care system as well as the financial and non-financial spillovers that these uninsurance-related contexts generate.

Title from cover. An international journal on population differences in disease patterns.

Antiracist health policy research requires methodological innovation that creates equity-centered and antiracist solutions to health inequities by centering the complexities and insidiousness of structural racism. The development of effective health policy and health equity interventions requires sound empirical characterization of the nature of structural racism and its impact on public health. However, there is a disconnect between the conceptualization and measurement of structural racism in the public health literature. Given that structural racism is a system of interconnected institutions that operates with a set of racialized rules that maintain White supremacy, how can anyone accurately measure its insidiousness? This article highlights methodological approaches that will move the field forward in its ability to validly measure structural racism for the purposes of achieving health equity. We identify three key areas that require scholarly attention to advance antiracist health policy research: historical context, geographical context, and theory-based novel quantitative and qualitative methods that capture the multifaceted and systemic properties of structural racism as well as other systems of oppression.

Background:Maternity care is important for healthy outcomes. The need to switch providers mid-pregnancy may be disruptive to continuity and quality of care. However, little is known about how often switching occurs, and what factors contribute to a woman's desire to switch. We compared the factors and incidence of switching providers during pregnancy among a national sample of white and black women.