Storylines of family medicine X: standing up for diversity, equity and inclusion

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'X: standing up for diversity, equity and inclusion', authors address the following themes: 'The power of diversity-why inclusivity is essential to equity in healthcare', 'Medical education for whom?', 'Growing a diverse and inclusive workforce', 'Therapeutic judo-an inclusive approach to patient care', 'Global family medicine-seeing the world "upside down"', 'The inverse care law', 'Social determinants of health as a lens for care', 'Why family physicians should care about human rights' and 'Toward health equity-the opportunome'. May the essays that follow inspire readers to promote change.

"I'm not Alone; He will be There for Me": A Mixed-Method Approach Exploring the Impact of Spousal Support on Mammogram Utilization and Health Beliefs

Regular mammogram screenings are effective for early breast cancer (BC) detection and decreased mortality rate. However, immigrant Muslim Arab women (IMAW) are less likely to adhere to these screenings although the rate of BC among IMAW is high. Recent studies have explored low mammogram screening rates among immigrant Muslim and/or Arab women from a limited perspective, overlooking the fact that husbands have an influence in IMAW's health behaviors toward cancer screenings. Thus, this mixed-method approaches were employed to (a) explore the association between spousal support and IMAW's health beliefs toward mammograms and their utilization, (b) to understand IMAW's experiences of spousal influence related to their mammogram use and health beliefs. The quantitative portion of the study, recruitment and data collection were conducted via online surveys in Arabic and English. Logistic regressions were used to explore relationships between perceived spousal support and IMAW's mammogram utilization and health beliefs. The qualitative portion of the study was conducted on a purposive sample of IMAW. A semi-structured interview guide in Arabic and English was used during one-on-one interviews. Arabic interviews were translated into English and transcribed by professionals. Interviews were analyzed by thematic analysis according to Braun and Clarke (2008). A total of 184 IMAW completed the survey with mean age of 50.4 (SD = 5.58, range = 45-60). Results revealed low mammogram screening rate among IMAW. Only 32.6% adhered to mammograms. Spousal support was positively associated with ever having obtained a mammogram and IMAW's adherence to mammogram. The 20 qualitative interviews, 16 in Arabic and four in English, produced rich description supporting results from the survey which includes, (a) types of spousal support, (b) impact of spousal support on participants' mammogram utilization and experience, and (3) impact of spousal support on participants' health beliefs toward mammograms. Findings from surveys and interviews show that a husband's support is positively associated with IMAW's mammogram utilization and health beliefs. Suggesting a new approach to integrate husbands in culturally appropriate interventions to increase mammogram screening rates among IMAW.

The Stress of Advancement: A Nurse Practitioner's Exploration in Providing Culturally Competent Obesity Prevention Counseling in Black Women

BACKGROUND

Black women are diagnosed, disabled, and die from obesity and associated chronic diseases at higher rates than any other sex or race. Advanced practice registered nurses (APRN) can potentially improve culturally relevant health education and counseling by using health literacy communication tools.

OBJECTIVE

Explore individualized barriers and APRNs' role in providing obesity prevention education and counseling by assessing the efficacy of the Teach-Back Method (TBM) to understand health habits and attitudes.

METHODS

Black women aged 18-45, previously diagnosed as overweight or obese, and identified with perceived barriers were recruited from a predominantly Black church in Atlanta. They engaged in weekly, 1-hour educational sessions via Zoom, addressing four common barriers identified in the literature. Sessions ended with a 5-10 minute Teach-Back session. Pre- and post-intervention Readiness to Change Questionnaire (RCQ) were completed. Descriptive statistics and quantitative data from surveys and pre- and post-RCQ were analyzed.

RESULTS

Twenty women completed the intervention. Paired sample t-test revealed no statistical significance or correlation between pre- and post-RCQ scores after using TBM in educational sessions. However, Pearson's correlation showed positive associations between elevated body mass index levels as one advances their education and annual income, with a p-value of 0.05.

DISCUSSION

Increased rates of obesity are experienced despite higher educational attainment or pay. Stress and high-coping mechanisms contributed to disordered eating, decreased physical activity engagement, and decreased motivation toward habit change. Clinicians should be held accountable for delivering culturally sensitive care using the TBM, addressing social determinants of health, performing routine stress assessments, and checking their implicit biases.

Virtual Music Therapy for Substance Use Disorders in a Federally Qualified Health Center

BACKGROUND

Music therapy (MT) is an effective adjunctive treatment for substance use disorders (SUD), which is primarily available in inpatient treatment centers and rarely provided in outpatient primary care.

METHODS

We evaluated the feasibility and acceptability of a virtual group MT program for SUD in a Federally Qualified Health Center (FQHC), and secondarily assessed patient perceptions of its effect. Feasibility was measured by implementation-related process measures, attendance and use of technology. Qualitative interviews eliciting participant perceptions were conducted to evaluate acceptability and effect. Mood scores, substance use and craving were measured before and after the intervention.

RESULTS

Onboarding of the music therapist took 3.5 months. All MT sessions were attended by 1 to 5 individuals out of 6. Participants reported that group MT was "soothing" and "calming," gave them tools to treat cravings and stress, and created a sense of community. They reported that during sessions their cravings decreased. Anxiety and depression scores trended down, as did the number of days of substance use. They all stated they would seek out MT again.

DISCUSSION

Our results suggest that remote group MT is feasible and acceptable to our FQHC patients with SUD. Patients reported an improvement in mood and their ability to manage stress, and a decrease in substance use.

CONCLUSION

We wish to build on the results of this study to enhance our understanding of the effects of MT in the outpatient setting, and broaden our patients' access to MT in primary care.

Color Coded Care

The work of physicians and healthcare workers in taking care of our family and loved ones, saving lives, are a sacred task. Still, we recognize through data, that our healthcare systems are contrarily filled with inequities and medical bias that results in harm. Often, these inequities are felt among minoritized and marginalized groups, or in the case of "Color Coded Care," my mother, a retired nurse, ordained minister, wife, grandmother, and black woman. This original prose poetry piece highlights events that occurred during her 41 days of hospitalization in a neuro-intensive care unit in Florida. It is important to note that the content of this prose may trigger feelings of discomfort, particularly among providers who have taken the great Oath to give their patients the best care possible. However, it may also be a valuable and cathartic step toward repairing medical mistrust by bringing voice to experiences of healthcare related trauma. "Color Coded Care" is not an indictment, rather, it is a cry for the work that is being done to remove inequity and harmful medical bias from our healthcare systems. It is the hope for a more equitable tomorrow. "To view the original version of this poem, see the supplemental material section of this article online."

Validation of a Questionnaire on Sexual and Reproductive Health Among Immigrant Vocational Education Students in Portugal from São Tomé and Príncipe

Sexual and reproductive health interventions' effectiveness should be evaluated using a valid instrument. This study aimed to validate a questionnaire on sexual and reproductive health in adolescents and young adults from São Tomé and Príncipe who voluntarily enrolled in a vocational school in Portugal to complete their 12th school year and obtain a professional card.A questionnaire consisting of perception and knowledge sections was adapted from previous questionnaires. We followed the steps of psychometric analysis. Firstly, we assessed face validity and content validity. We used factorial analysis to validate the perceptions section (which included Likert-type questions). For the knowledge section (which consisted of multiple-choice questions), we used the key check, discrimination index, and difficulty index. We evaluated internal consistency through Cronbach's alpha for the perceptions section and the Kuder-Richardson score for the knowledge section.Out of 105 invited students, a total of ninety students were enrolled in this study, of whom 88 completed most of the questions. The exploratory analysis showed that most students agreed with the right to refuse intercourse. However, while approximately 23% disagreed that consensual sex among adult women or men is always wrong, around the same proportion agreed. A considerable number of students recognized condoms and pills as effective methods of contraception. However, most students were unfamiliar with other methods. Most knowledge questions showed acceptable difficulty levels, and the discrimination index varied among questions. The knowledge questions demonstrated good consistency levels. This study enabled us to develop an appropriate instrument for evaluating the effectiveness of public health interventions and identifying specific knowledge gaps in migrant populations from low-income countries. This will help prioritise topics to be addressed in sexual health education sessions.

Diversity and Representation Among United States Participants in Amgen Clinical Trials

OBJECTIVE

Describe the demographic profile of US participants in Amgen clinical trials over a 10-year period and variations across therapeutic areas, indications, and geographies.

METHODS

Cross-sectional retrospective study including participants enrolled (2005-2020) in phase 1-3 trials completed between January 1, 2012 and June 30, 2021.

RESULTS

Among 31,619 participants enrolled across 258 trials, one-fifth represented racial minority populations (Asian, 3%; Black or African American, 17%; American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, multiracial, each < 1%); fewer than one-fifth (16%) represented an ethnic minority population (Hispanic or Latino). Compared with census data, representation of racial and ethnic groups varied across US states. Across most therapeutic areas (bone, cardiovascular, hematology/oncology, inflammation, metabolic disorders, neuroscience) except nephrology, participants were predominantly White (72-81%). A similar proportion of males and females were enrolled between 2005 and 2016; male representation was disproportionately higher than female between 2016 and 2020. Across most medical indications, the majority of participants were 18-65 years of age.

CONCLUSIONS AND RELEVANCE

While the clinical research community is striving to achieve diversity and proportional representation across clinical trials, certain populations remain underrepresented. Our data provide a baseline assessment of the diversity and representation of US participants in Amgen-sponsored clinical trials and add to a growing body of evidence on the importance of diversity in clinical research. These data provide a foundation for strategies aimed at supporting more equitable and representative research, and a baseline from which to assess the impact of future strategies to advance health equity.

Perspectives on Non-Prescription Antibiotic Use among Hispanic Patients in the Houston Metroplex

BACKGROUND

Non-prescription antibiotic use includes taking an antibiotic without medical guidance (e.g., leftovers, from friends/relatives, or purchased without a prescription). Non-prescription use contributes to antimicrobial resistance, adverse drug reactions, interactions, superinfection, and microbiome imbalance. Qualitative studies exploring perspectives regarding non-prescription use among Hispanic patients are lacking. We used the Kilbourne Framework for Advancing Health Disparities Research to identify factors influencing patients' non-prescription use and organize our findings.

METHODS

Our study includes Hispanic primary care clinic patients with different types of health insurance coverage in the Houston metroplex who endorsed non-prescription use in a previous survey. Semistructured interviews explored the factors promoting non-prescription use in Hispanic adults. Interviews were conducted remotely, in English or Spanish, between May 2020 and October 2021. Inductive coding and thematic analysis identified motives for non-prescription use.

RESULTS

Participants (n = 35) were primarily female (68.6%) and aged 27 to 66. Participants reported obtaining antibiotics through trusted persons, sold under-the-counter in US markets, and purchased without a prescription abroad. Factors contributing to non-prescription use included beliefs that the doctor visit was unnecessary, limited access to healthcare (due to insurance constraints, costs, and clinic wait times), and communication difficulties (e.g., language barriers with clinicians and perceived staff rudeness). Participants expressed confidence in medical recommendations from pharmacists and trusted community members.

CONCLUSIONS

Patient, healthcare system, and clinical encounter factors contribute to non-prescription use in Hispanic communities. Antibiotic stewardship interventions that involve pharmacists and trusted persons, improve access to care, and address communication barriers and cultural competency in the clinic may help reduce non-prescription use in these communities.

Study protocol of a telephone problem-solving intervention for Spanish-speaking caregivers of veterans post-stroke: an 8-session investigator-blinded, two-arm parallel (intervention vs usual care), randomized clinical trial

BACKGROUND

Stroke is one of the leading causes of death and the main cause of long-term disability in the United States. The significant risk factors of stroke among Hispanics are well-documented. The majority of stroke survivors return home following a stroke and are cared for by family caregivers. Due to the abrupt nature of strokes, caregivers experience unexpected changes and demands that oftentimes lead to caregiver burden and depression. Given the significant risk factors for stroke in Hispanics and the influence of culture in family norms and family management, we developed a telephone and online problem-solving intervention for Spanish-speaking stroke caregivers. This study tests the impact of a telephone and online problem-solving intervention for Spanish-speaking stroke caregivers on caregiver outcomes.

METHODS

The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 290 caregivers from 3 Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a problem-solving intervention that uses telephone and online education and care management tools on the previously developed and nationally available RESCUE en Español Caregiver website. In the usual care group, participants receive the information and/or support caregivers of veterans with stroke normally receive through existing VA resources (e.g., stroke-related information and support). The primary outcome is change in caregiver's depressive symptoms at 1- and 12-weeks post-intervention. Secondary outcomes include changes in stroke caregivers' burden, self-efficacy, problem-solving, and health-related quality of life (HRQOL) and veterans' functional abilities. We will also determine the budgetary impact, the acceptability of the intervention and participation barriers and facilitators for Spanish-speaking stroke caregivers.

DISCUSSION

This is an ongoing study. It is the first known randomized controlled trial testing the effect of a telephone and online problem-solving intervention in Spanish for caregivers of veterans post-stroke. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post-stroke.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03142841- Spanish Intervention for Caregivers of Veterans with Stroke (RESCUE Español). Registered on February 23, 2018. Protocol version 8. 08.11.2022.

Recruitment of Young Black Men into Trauma and Mental Health Services Research: Recommendations and Lessons Learned

Young Black/African American men are more likely to experience repeated trauma that escalates throughout young adulthood, compared to young White men. Exposure to trauma has impacts on mental health outcomes, but young Black men face substantial barriers to mental health care. In order to begin to address these disparities, it is imperative to increase understanding of the needs, preferences, and priorities of young Black men for mental health care services following trauma. Yet, young Black men are often underrepresented in mental health services research. The purpose of the current study was to describe strategies for recruitment of young Black men with previous trauma exposure from broad urban community settings in Kansas City, Missouri, for participation in a qualitative study exploring beliefs, attitudes, and norms regarding mental health care. A total of 70 young Black/African American men aged 18-30 completed the initial recruitment process, and 55 of these men were consented as participants who completed the study. The majority of participants were recruited from barbershops (n = 21), followed by community-wide events (n = 11) and referrals (n = 11). Few participants were recruited from faith-based settings. Strategies for facilitation of study recruitment and focus group attendance are discussed. These practices may contribute to development of mental health interventions that are relevant, feasible, and sustainable, as well as restoring and advancing research relationships with racial/ethnic minority populations and contributing to racial equity.

Attribution for everyday discrimination typologies and mortality risk among older black adults: Evidence from the health and retirement study?

BACKGROUND

The present study assessed how attributions of everyday discrimination typologies relate to all-cause mortality risk among older Black adults.

METHODS

This study utilized data from a subsample of older Black adults from the 2006/2008 Health and Retirement Study (HRS). Attributions for everyday discrimination (i.e., ancestry, age, gender, race, physical appearance, physical disability, sexual orientation, weight, and other factors) were based on self-reports, while their vital statuses were obtained from the National Death Index and reports from key informants (spanning 2006-2019). We applied latent class analysis (LCA) to identify subgroups of older Black adults based on their attributions to everyday discrimination. Cox proportional hazards models were used to analyze time to death as a function of LCA group membership and other covariates.

RESULTS

Based on fit statistics, we selected a four-class model that places respondents into one of the following classes: Class One (7%) attributed everyday discrimination to age, race, and physical disability; Class Two (72%) attributed everyday discrimination to few/no sources, Class Three (19%) attributed everyday discrimination to race and national origin; and Class Four (2%) attributed everyday discrimination to almost every reason. After adjusting for sociodemographic, behavioral, multisystem physiological dysregulation, and socioeconomic characteristics, we found that the relative risk of death remained higher for the respondents in Class One (Hazard Ratio [H.R.]: 1.80, 95% Confidence Interval [C.I.]: (1.09-2.98) and Class Four (H.R.: 3.92, 95% C.I.: 1.62-9.49) compared to respondents in Class Two.

CONCLUSIONS

Our findings illustrate the utility of using attribution for everyday discrimination typologies in research on the psychosocial dimensions of mortality risk among older Black adults. Future research should assess the mechanisms that undergird the link between everyday discrimination classes and all-cause mortality risk among older Black adults.

Addressing and Dismantling the Legacy of Race and Racism in Academic Medicine: A Socioecological Framework

Over the past several years, in both clinical and academic medicine, there seems to be a growing consensus that racial/ethnic health inequities result from social, economic and political determinants of health rather than from nonexistent biological markers of race. Simply put, racism is the root cause of inequity, not race. Yet, methods of teaching and practicing medicine have not kept pace with this truth, and many learners and practitioners continue to extrapolate a biological underpinning for race. To achieve systemic change that moves us toward racially/ethnically equitable health outcomes, it is imperative that medical academia implement policies that explicitly hold us accountable to maintain a clear understanding of race as a socio-political construct so that we can conduct research, disseminate scholarly work, teach, and practice clinically with more clarity about race and racism. This short commentary proposes the use of a socioecological framework to help individuals, leadership teams, and institutions consider the implementation of various strategies for interpersonal, community-level, and broad institutional policy changes. This proposed model includes examples of how to address race and racism in academic medicine across different spheres, but also draws attention to the complex interplay across these levels. The model is not intended to be prescriptive, but rather encourages adaptation according to existing institutional differences. This model can be used as a tool to refresh how academic medicine addresses race and, more importantly, normalizes conversations about racism and equity across all framework levels.

Associations Between Healthcare Experiences, Mental Health Outcomes, and Substance Use Among Transgender Adults

INTRODUCTION

Transgender and nonbinary (TGNB) adults face significant barriers to healthcare, including healthcare denials, limited access to clinicians, and mistreatment by healthcare clinicians. While prior studies have explored the consequences of overt discrimination in healthcare, they often overlook the possible impacts of more subtle forms of discrimination.

AIM

Is there a relationship between specific healthcare experiences, including both overt and subtle forms of discrimination, and mental health/substance use among TGNB adults?

METHODS

This study was a secondary analysis of the 2015 U.S. Transgender Survey (USTS), a cross-sectional survey conducted by the National Center for Transgender Equality (NCTE) that included 27,715 TGNB adults from across the US and several US territories. This study analyzed variables including healthcare experiences, mental health, and substance use outcomes.

RESULTS

Doctors refusing to give non-TGNB-related care was associated with 71% increased odds of severe psychological distress and 95% increased odds of suicidal ideation. Further, having to teach doctors about TGNB care and doctors asking invasive questions were associated with all our studied negative mental health outcomes. Doctors asking invasive questions was additionally related to increased odds of heavy alcohol use, marijuana use, and illicit drug use.

CONCLUSIONS

The results of this study indicate that negative health care experiences are significantly associated with mental health and substance use for TGNB adults. Specifically, these results emphasize the role of more subtle forms of discrimination, including a lack of clinician knowledge about the care of TGNB patients, asking invasive questions, and treating TGNB patients with respect.

The COVID-19 Pandemic in a Hispanic Population: A Primary Care Perspective

INTRODUCTION

The COVID-19 global pandemic has affected all ethnic and minority groups although not equally. The goals of the present study are twofold: describe the diverse COVID-19-related care needs Hispanic patients presenting to a primary care facility and the symptom clusters and socioeconomic factors that may impact their wellbeing.

METHODS

This is a retrospective cohort of Hispanic patients in an outpatient clinic serving an urban lower socioeconomic demographic, between May 9 and July 31, 2020. COVID-19 infection was confirmed by polymerase chain reaction or rapid antibody test. Student's t-test was used for means and the chi² was used for comparisons of proportions.

RESULTS

A total of 6616 patients visited Alivio, 409 were triaged to a containment area, and 378 were tested for COVID-19; 230 with, 148 without symptoms. Of those tested, 161(42.6%) were positive, representing 2.4% of total patients seen. Age, temperature, and pulse rate were all significantly higher in patients with symptoms compared with those without. Symptoms were grouped into 5 clusters: constitutional, n = 143(62%), respiratory, n = 136 (59%), and somatic, n = 97(42%) were most common. No single cluster was particularly diagnostic of COVID-19, although those with symptoms in multiple clusters were more likely to test positive, P < .001. The majority worked in essential jobs, were uninsured, and had more than half had prolonged symptoms.

CONCLUSIONS

Hispanic patients have diverse reasons for seeking health care and for testing in a pandemic. COVID-19 is a syndromic disease as evidenced from the clustering of symptoms. Essential workers and uninsured health status may lead to more prolonged disease course.

Post-Pandemic Telehealth Policy for Primary Care: An Equity Perspective

National telehealth policy thus far has focused on broadening access to service, specialties, and originating sites. Yet telehealth policy can further equity by providing system-level change needed to reduce structural determinants that hamper telehealth access in historically marginalized, low income, and limited English-speaking populations. The authors propose policy solutions for states and CMS to help address these structural determinants of telehealth care. A telehealth "ecosystem" grounded in the following core components would ensure equitable access to care: use of technology inclusive of economically marginalized patients, access to the technology and broadband for completing virtual visits, and concrete support for patients as they develop their digital and telehealth skills.

Implementation of Transgender/Gender Nonbinary Care in a Family Medicine Teaching Practice

PURPOSE

Numerous studies have shown that transgender or gender nonbinary (TGNB) individuals encounter significantly more health care barriers, including overall lack of access to gender-affirming care providers. This study describes 2 assessments of transgender care services at a large family medicine teaching practice.

METHODS

Staff and providers were invited to attend an optional, practice-wide, hourlong free training session on gender-affirming care offered on 3 different dates in 2019. A structured protocol was used to collect observational data from which key takeaways from the training sessions were developed. Separately, a retrospective chart review of patients with a gender dysphoria diagnosis was completed. Charts were reviewed for adherence to regional and international organization recommendations for comprehensive transgender care.

RESULTS

Three main takeaways from the training sessions included lack of knowledge or familiarity with gender terminology and expression, fear of offending patients, and employee hesitation to change behaviors when interacting with patients. On chart review, the most common interventions identified were need to schedule a follow-up visit (61.5%), need for health maintenance screenings (osteoporosis screening, 50%; Papanicolaou smear, 56.3%; mammogram, 66.7%), need for mental health screening (41.5%), need for laboratory monitoring of testosterone therapy (20%), and corrected gender markers/names listed in the appropriate place in the patient chart (16.9%).

CONCLUSIONS

This study highlighted hesitation to provide and lack of familiarity with transgender care among practice staff. Although some aspects of comprehensive transgender care are well implemented, maintaining follow-up, completing health maintenance and mental health screenings, and appropriate laboratory monitoring are areas for improvement.

Lifetime stressor exposure, systemic inflammation during pregnancy, and preterm birth among Black American women

Although Black American mothers and infants are at higher risk for morbidity and mortality than their White counterparts, the biological mechanisms underlying these phenomena remain largely unknown. To investigate the role that lifetime stressor exposure, perceived stressor severity, and systemic inflammatory markers might play, we studied how these factors were interrelated in 92 pregnant Black American women. We also compared inflammatory marker levels for women who did versus did not go on to give birth preterm. During the early third trimester, women completed the Stress and Adversity Inventory for Adults to assess the stressors they experienced over their lifetime. Women also provided blood samples for plasma interleukin (IL)-6, IL-8, IL-1β, and tumor necrosis factor (TNF)-α quantification. Preterm births were identified by medical record review. Controlling for relevant covariates, there were significant positive associations between average levels of both overall and acute perceived stressor severity and plasma IL-1β levels. Controlling for perceived stress at assessment and exposure to racial discrimination did not affect these results. Mediation models revealed that exposure to more chronic stressors was related to higher plasma IL-1β levels, as mediated by higher average levels of overall perceived stressor severity. Exposure to fewer acute stressors was related to higher plasma IL-1β levels, as mediated by higher average levels of acute perceived stressor severity. Finally, women who went on to give birth preterm had higher levels of plasma IL-6. These data thus highlight the potential importance of assessing and addressing lifetime stressor exposure among mothers before and during maternal-infant care.

Underrepresented Minority Family Physicians More Likely to Care for Vulnerable Populations

Using data from 2016 to 2020, we found that family physicians who identify as underrepresented minorities in medicine were more likely to have a larger percentage of vulnerable patients in their panels. Increasing access to care for vulnerable patient populations will require a combination of advocating for policies to diversify the physician pipeline and those that encourage all primary care physicians to care for vulnerable patients.

Validating the Group-Based Medical Mistrust Scale with English and Spanish Speaking Latino Parents of Adolescents

BACKGROUND

Medical mistrust can be a barrier to health care utilization. While the Group-Based Medical Mistrust Scale (GBMMS) has been validated among diverse populations, we know little about its psychometric performance among English-Speaking (ES) and Spanish-Speaking (SS) Latinos. We aim to examine the factor structure of GBMMS among Latino parents and explore whether scale latent factor structures would be different across preferred languages.

METHODS

Parents of adolescents participating in an urban academic enrichment program for low-income students completed an online survey as part of a cross-sectional study about Human Papillomavirus (HPV) prevention. We tested the validity of the GBMMS in ES and SS respondents and performed exploratory factor analysis to identify latent factors. We examined scale scores, item means, item endorsement, and residual variance across language groups.

RESULTS

2-factor latent structure was identified for both ES and SS groups; factors were labeled as 'Suspicion' and 'System-wide discrimination.' Scale validity was better among SS (α = 0.76). Medical mistrust scores did not vary across language groups, but variation emerged in item endorsement by language.

DISCUSSION

Our results suggest that the factor structures of the medical mistrust construct, measured by the GBMMS, are similar across ES and SS Latinos and that the GBMMS is valid for both populations. High factor pattern loading reflects a shared mistrust of how health care systems view and treat people of their racial/ethnic background, independent of their preferred languages. Measurement of medical mistrust and identifying its underlying causes are needed within diverse populations to fully address structural- and community-level influences on health inequities.

Advancing Inclusive Research: Establishing Collaborative Strategies to Improve Diversity in Clinical Trials

Well-characterized disparities in clinical research have disproportionately affected patients of color, particularly in underserved communities. To tackle these barriers, Genentech formed the External Council for Advancing Inclusive Research, a 14-person committee dedicated to developing strategies to increase clinical research participation. To help improve the recruitment and retention of patients of color, this article chronicles our efforts to tangibly address the clinical research barriers at the system, study, and patient levels over the last four years. These efforts are one of the initial steps to fully realize the promise of personalized health care and provide increased patient benefit at less cost to society. Instead of simply acknowledging the problem, here we illuminate the collaborative and multilevel strategies that have been effective in delivering meaningful progress for patients.

Can Family Medicine's Counterculture History Help Shape an Anti-Racist Future?

Family medicine prides itself on community engagement and has embraced its counterculture roots. After the racial and social reckoning of 2020, including the COVID-19 pandemic and the Black Lives Matters movement, family medicine, as a specialty, must embrace anti-racism as a core value to meet community needs. This article reflects on the foundational tenets of family medicine's origin. It highlights the current disparities regarding professional representation while offering equitable, intentional, and collaborative approaches to move toward and achieve anti-racism within the specialty, medical education, and the community.

Community-Based Health Care Navigation's Impact on Access to Primary Care for Low-Income Latinos

INTRODUCTION

Despite the Affordable Care Act's insurance expansion, low-income Latinos are less likely to have a primary care provider compared with other racial/ethnic and income groups. We examined if community-based health care navigation could improve access to primary care in this population.

METHODS

We surveyed adult clients of a community-based navigation program serving predominantly low-income Latinos throughout Los Angeles County in 2019. We used multivariable logistic regression models, adjusting for sociodemographic characteristics, to calculate odds ratios for differences in access to primary care and barriers to care between clients who had experienced approximately 1 year of navigation services (intervention group) and clients who were just introduced to navigation (comparison group).

RESULTS

Clients in the intervention group were more likely to report having a primary care clinic than the comparison group (Adjusted Odds Ratio [aOR] 3.0, 95%CI: 1.7, 5.4). The intervention group was also significantly less likely to experience several barriers to care, such as not having insurance, not being able to pay for a visit, and not having transportation.

CONCLUSIONS

Community-based navigation has the potential to reduce barriers and improve access to primary care for low-income Latinos. In addition to expanding insurance coverage, policymakers should invest in health care navigation to reduce disparities in primary care.

Life Satisfaction and Social and Emotional Support Among Asian American Older Adults

BACKGROUND

Little data exist on the well-being of older adults from Asian American (AA) communities.

METHODS

Using data from the 2018 California Health Interview Survey, we examined 2 well-being metrics among AAs and AA subgroups (Korean, Filipino, Vietnamese, Chinese) 65 years and older.

RESULTS

AA older adults reported lower life satisfaction and not having needed social and emotional support compared with all other race/ethnicities. Current life satisfaction among AA older adults was 54% compared with 80% for all other race/ethnicities; 56% of AA older adults reported usually or always receiving social/emotional compared with 80% for all other race/ethnicities. Within the AA category, life satisfaction was 40% for Korean, 48% for Chinese, 47% for Vietnamese, and 77% for Filipino older adults. Among Korean older adults, 30% reported receiving needed social/emotional support, 57% among Chinese, 59% among Filipino, and 65% among Vietnamese older adults.

CONCLUSION

AA older adults report lower life satisfaction and not needed receiving social and emotional support compared with all other race/ethnicities. Among AAs, Korean older adults were most likely to report poorer well-being. AA older adult communities may be in urgent need of further research and investment in interventions.

Food insecurity and chronic diseases among Native Hawaiians and Pacific Islanders in the US: results of a population-based survey

Data from the 2014 Native Hawaiian and Pacific Islander (NHPI) National Health Interview Survey were used to examine associations between food security and individual chronic diseases, total number of chronic diseases, and general health status among 637 NHPI adults with income below 200 percent federal poverty level. Very low food security was associated with hypertension, diabetes, and asthma. Very low food security and marginal food security were associated with having any chronic disease and with having a higher number of chronic diseases. Risk for food insecurity increased as health status decreased. These associations had not previously been documented for NHPI.

Considerations for Transgender Population Health Research Based on US National Surveys

Transgender identities and health are highly politicized in the United States leading to restrictions on relevant data collection in national health surveillance systems. This has serious implications on transgender population health research; an urgent area of study given the systemic discrimination faced by transgender individuals and the resultant social and health inequities. In this precarious political climate, obtaining high-quality data for research is challenging and in recent years, two data sources have formed the foundation of transgender health research in the United States, namely the 2015 United States Transgender Study and the Behavioral Risk Factor Surveillance System (BRFSS) after the launch of the optional Sexual Orientation and Gender Identity Module in 2014. While useful, there are serious challenges to using these data to study transgender health, specifically related to survey weighting methodologies, ascertainment of gender identity, and study design. In this article, we detail these challenges and discuss the strengths and weaknesses of various methodological approaches that have been implemented as well as clarify several common errors that exist in the literature. We feel that this contribution is necessary to provide accurate interpretation of the evidence that currently informs policy and priority setting for transgender population health and will provide vital insights for future studies with these now ubiquitous sources of data in the field.

Social and Behavioral Factors Associated with BMI and Waist Circumference among Adolescents: The Jackson Heart KIDS Pilot Study

Background

African American children and adolescents make up a disproportionately large segment of those classified as overweight and obese. The purpose of this study was to examine social and behavioral factors associated with accelerated accumulation of weight and adiposity among this group.

Methods

The data for this cross-sectional study were drawn from the Jackson Heart KIDS Pilot Study - an offspring cohort study comprising 12- to 19-year-old descendants of Jackson Heart Study participants (N=212). Body mass index (BMI) and waist circumference were the outcomes of interest. Daily hassles, fruit and vegetable consumption, physical activity, television watching, parent/grandparent weight status and participant birth weight, age and sex were the independent variables included in the analyses.

Results

Males and females were equally represented in the study and the mean BMI and waist circumference for adolescents in the study was 25.81±7.78 kg/m² and 83.91 ± 19.81 cm, respectively. Fully adjusted linear regression models for the total sample produced results indicating that age, television viewing, weight control, and parental weight status were positively associated with BMI and waist circumference, respectively. Findings from sex-stratified models for BMI and waist circumference indicated that the significance of coefficients for age, television viewing, and parent/grandparent weight status varied by sex.

Conclusions

Knowledge is limited about how sex or gender interact with social and behavioral factors to influence African Americans' health and additional studies are needed to specify how these factors interact to accelerate weight gain and adipose tissue accumulation over the life course.

Legacies of Environmental Injustice on Neighborhood Violence, Poverty and Active Living in an African American Community

Features of the built environment such as parks and open spaces contribute to increased physical activity in populations, while living in neighborhoods with high poverty, racial/ethnic segregation, presence of neighborhood problems, and violence has been associated with less active living. Our present study examined the factors that may facilitate or hinder the long-term success of built environment interventions aimed at promoting physical activity in communities with a legacy of environmental injustice. The data for this study came from a larger assessment of the impact of a new local park in Newark, NJ. Analysis included all adults from the original study population who self-identified as African American/Black (N=95). To provide an in-depth understanding of how neighborhood social and physical features influence physical activity among African Americans living in high poverty neighborhoods, we analyzed data from two focus groups with a total of 14 participants, and six in-depth interviews held in 2009-2010. Survey results indicated high exposure to violence, and associations between neighborhood features and walking. Self-reported neighborhood walkability was associated with increased walking (P=.01), while increased perception of neighborhood safety was associated with less walking (P=.01). Qualitative results indicated that residents perceived the new park as a positive change, but also expressed concern about the presence of violence and lack of social cohesion among neighbors, with younger generations expressing less optimism than the elderly. Positive changes associated with improvements to the built environment may be limited by social conditions such as neighborhood violence. These mixed findings suggest that policies and initiatives aimed at improving the built environment should address poverty, safety, and social cohesion to ensure more active living communities.

The Role of Community-Based Organizations in Improving Chronic Care for Safety-Net Populations

INTRODUCTION

Social determinants of health (SDoH) influence health outcomes and contribute to disparities in chronic disease in vulnerable populations. To inform health system strategies to address SDoH, we conducted a multi-stakeholder qualitative study to capture the multi-level influences on health for those living in socio-economically deprived contexts.

METHODS

Varied qualitative inquiry methods - in-depth interviews, participant-led neighborhood tours, and clinic visit observations - involving a total of 23 participants (10 patients with chronic illnesses in San Francisco neighborhoods with high chronic disease rates, 10 community leaders serving the same neighborhoods, and 3 providers from San Francisco's public health care delivery system). Qualitative analyses were guided by the Chronic Care Model (CCM).

RESULTS

Several key themes emerged from this study. First, we enumerated a large array, neighborhood resources such as food pantries, parks/green spaces, and financial assistance services that interact with patients' self-management. Health service providers leveraged these resources to address patients' social needs but suggested a clear need for expanding this work. Second, analyses uncovered multiple essential mechanisms by which community-based organizations (CBOs) provided and navigated among many neighborhood health resources, including social support and culturally aligned knowledge. Finally, many examples of how structural issues such as institutional racism, transportation, and housing inequities are intertwined with health and social service delivery were elucidated.

CONCLUSION

The results contribute new evidence toward the community domain of the CCM. Health care systems must intentionally partner with CBOs to address SDoH and improve community resources for chronic care management, and directly address structural issues to make progress.

Predictors of medical mistrust among urban youth of color during the COVID-19 pandemic

The COVID-19 pandemic has disproportionately impacted communities of color and highlighted longstanding racial health inequities. Communities of color also report higher rates of medical mistrust driven by histories of medical mistreatment and continued experiences of discrimination and systemic racism. Medical mistrust may exacerbate COVID-19 disparities. This study utilizes the Behavior Model for Vulnerable Populations to investigate predictors of medical mistrust during the COVID-19 pandemic among urban youth of color. Minority youth (N = 105) were recruited from community organizations in Kansas City, Missouri to complete an online survey between May and June 2020. Multiple linear regressions were performed to estimate the effect of personal characteristics, family and community resources, and COVID-19 need-based factors on medical mistrust. Results indicated that loneliness, financial insecurity (e.g., job loss, loss of income) due to the COVID-19 pandemic, and eligibility for free or reduced lunch predicted medical mistrust. Insurance status, neighborhood median household income, social support, and perceived COVID-19 risk were not significantly associated with medical mistrust. Future research and policies are necessary to address systemic factors that perpetuate medical mistrust among youth of color.

Now Is the Time to Incorporate the Construct of Structural Racism and Discrimination into Health Research

Ethn Dis. 2021;31(Suppl 1):283-284;doi:10.18865/ed.31.S1.283

Family Medicine With Refugee Newcomers During the COVID-19 Pandemic

Certain members of society are disproportionately affected by the COVID-19 crisis and the added strain being placed on already overextended health care systems. In this article, we focus on refugee newcomers. We outline vulnerabilities refugee newcomers face in the context of COVID-19, including barriers to accessing health care services, disproportionate rates of mental health concerns, financial constraints, racism, and higher likelihoods of living in relatively higher density and multigenerational dwellings. In addition, we describe the response to COVID-19 by a community-based refugee primary health center in Ontario, Canada. This includes how the clinic has initially responded to the crisis as well as recommendations for providing services to refugee newcomers as the COVID-19 crisis evolves. Recommendations include the following actions: (1) consider social determinants of health in the new context of COVID-19; (2) provide services through a trauma-informed lens; (3) increase focus on continuity of health and mental health care; (4) mobilize International Medical Graduates for triaging patients based on COVID-19 symptoms; and (5) diversify communication efforts to educate refugees about COVID-19.

Native American Ancestry and Air Pollution Interact to Impact Bronchodilator Response in Puerto Rican Children with Asthma

Objective

Asthma is the most common chronic disease in children. Short-acting bronchodilator medications are the most commonly prescribed asthma treatment worldwide, regardless of disease severity. Puerto Rican children display the highest asthma morbidity and mortality of any US population. Alarmingly, Puerto Rican children with asthma display poor bronchodilator drug response (BDR). Reduced BDR may explain, in part, the increased asthma morbidity and mortality observed in Puerto Rican children with asthma. Gene-environment interactions may explain a portion of the heritability of BDR. We aimed to identify gene-environment interactions associated with BDR in Puerto Rican children with asthma.

Setting

Genetic, environmental, and psycho-social data from the Genes-environments and Admixture in Latino Americans (GALA II) case-control study.

Participants

Our discovery dataset consisted of 658 Puerto Rican children with asthma; our replication dataset consisted of 514 Mexican American children with asthma.

Main Outcome Measures

We assessed the association of pairwise interaction models with BDR using ViSEN (Visualization of Statistical Epistasis Networks).

Results

We identified a non-linear interaction between Native American genetic ancestry and air pollution significantly associated with BDR in Puerto Rican children with asthma. This interaction was robust to adjustment for age and sex but was not significantly associated with BDR in our replication population.

Conclusions

Decreased Native American ancestry coupled with increased air pollution exposure was associated with increased BDR in Puerto Rican children with asthma. Our study acknowledges BDR's phenotypic complexity, and emphasizes the importance of integrating social, environmental, and biological data to further our understanding of complex disease.

Interdisciplinary Primary Care Team Expertise and Diabetes Care Management

BACKGROUND

Interdisciplinary primary care team expertise can aid patient self management of type 2 diabetes, but small community health centers (CHCs) may not have the volume to consistently provide interprofessional care. We examine whether care team role expertise is associated with patients' experiences of chronic care and whether the relationship is stronger for small CHC sites.

METHODS

Surveys of 1277 adults with diabetes (2012; response rate = 47%) that assessed nonphysician team roles involved in managing their chronic care, including community health workers, diabetes educators, nutritionists, pharmacists, mental health providers, and other general staff, were integrated with clinical and administrative data from 14 CHCs. Random effects regression models estimated the association of team expertise, CHC size, and 1) patients' experiences of chronic care; and 2) hemoglobin A1c control, controlling for patient comorbidities, sex, race/ethnicity/primary language, age, and insurance coverage.

RESULTS

Care teams with community health workers ( β = 7.67, P < .01), diabetes educators ( β = 6.05, P < .01), nutritionists ( β = 5.21, P < .01), and other general staff ([Formula: see text] =4.96, P = .02) were associated with better patients' experiences of chronic care, but not hemoglobin A1c control. Patients of small CHC sites reported better experiences of care ( β = 2.15, P = .03) with each additional team role reported, but the relationship was not significant for large CHCs.

CONCLUSIONS

Patients with access to care team expertise in self-management support, including diabetes educators, nutritionists, community health workers, and other general staff report better experiences of chronic care. These team roles may reduce barriers to patient self management and improve patients' overall experiences of chronic care, particularly in small CHC sites.

Trends and Risk Factors for Leishmaniasis among Reproductive Aged Women in the United States

BACKGROUND AND OBJECTIVE

Leishmaniasis, a neglected tropical disease, is endemic in several regions globally, but commonly regarded as a disease of travelers in the United States (US). The literature on leishmaniasis among hospitalized women in the US is very limited. The aim of this study was to explore trends and risk factors for leishmaniasis among hospitalized women of reproductive age within the US.

METHODS

We analyzed hospital admissions data from the 2002-2017 Nationwide Inpatient Sample among women aged 15-49 years. We conducted descriptive statistics and bivariate analyses for factors associated with leishmaniasis. Utilizing logistic regression, we assessed the association between sociodemographic and hospital characteristics with leishmaniasis disease among hospitalized women of reproductive age in the US. Joinpoint regression was used to examine trends over time.

RESULTS

We analyzed 131,529,239 hospitalizations; among these, 207 cases of leishmaniasis hospitalizations were identified, equivalent to an overall prevalence of 1.57 cases per million during the study period. The prevalence of leishmaniasis was greatest among older women of reproductive age (35-49 years), Hispanics, those with Medicare, and inpatient stay in large teaching hospitals in the Northeast of the US. Hispanic women experienced a statistically significant increased odds of leishmaniasis diagnosis (OR, 1.80; 95% CI, 1.19-4.06), compared to Non-Hispanic (NH) White women. Medicaid and Private Insurance appeared to serve as a protective factor in both unadjusted and adjusted models. We did not observe a statistically significant change in leishmaniasis rates over the study period.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Although the prevalence of leishmaniasis among women of reproductive age appears to be low in the US, some risk remains. Thus, appropriate educational, public health and policy initiatives are needed to increase clinical awareness and timely diagnosis/treatment of the disease.

Low-Dose Aspirin Use Among African American Older Adults

OBJECTIVES

Existing epidemiologic information shows disparities in low-dose aspirin use by race. This study investigates the frequency, pattern, and correlates of both self- and clinician-prescribed low-dose aspirin use among underserved African Americans aged 55 years and older.

METHODS

This cross-sectional study conducted a comprehensive evaluation of all over-the-counter and prescribed medications used among 683 African American older adults in South Central Los Angeles, California. Correlation between use of low-dose aspirin and sociodemographic variables, health care continuity, health behaviors, and several major chronic medical conditions were examined. In addition, the use of low-dose aspirin as self prescribed versus clinician prescribed was examined. Multivariate logistic regression was performed to examine correlates of low-dose aspirin use.

RESULTS

Overall, 37% of participants were taking low-dose aspirin. Sixty percent of low-dose aspirin users were taking low-dose aspirin as self prescribed and 40% were taking it as prescribed by a clinician. Major aspirin-drug interactions were detected in 75% of participants who used low-dose aspirin, but no significant differences in aspirin-drug interactions were found between those who used aspirin as self prescribed and those who used it as clinician prescribed. No negative association between being diagnosed with gastrointestinal conditions and aspirin used was detected. Being diagnosed with diabetes mellitus or a heart condition was associated with higher use of aspirin. However, only 50% with high risk of cardiovascular took prescribed (38%) or self-prescribed (62%) low-dose aspirin. One third of participants aged 70 years and older with low risk of cardiovascular were using aspirin.

CONCLUSIONS

Among underserved African-American middle-aged and older adults, many who could potentially benefit from aspirin are not taking it; and many taking aspirin have no indication to do so and risk unnecessary side effects. Compared with non-Hispanic Whites, African Americans are more likely to be diagnosed with diabetes, hypertension, and heart conditions at earlier stages of life; as a result, the role of preventive intervention, including safe and appropriate use of low-dose aspirin among this segment of our population, is more salient. Interventional studies are needed to promote safe and effective use of low-dose aspirin among underserved African-American adults.

Evaluation of Recruitment of Older Adults of Color into a Community-Based Chronic Disease Self-Management Wellness Pathway Program in Los Angeles County

Background

Established relationships between researchers, stakeholders and potential participants are integral for recruitment of potential older adult participants and Evidence-Based Programs (EBPs) for chronic disease management have empirically been shown to help improve health and maintain healthy and active lives. To accelerate recruitment in EBPs and potential future research, we propose a Wellness Pathway allowing for delivery within multipurpose senior centers (MPCs) linked with medical facilities among lower-income urban older adults. The study aims were to: 1) assess the effectiveness of three MPC-delivered EBPs on disease management skills, health outcomes, and self-efficacy; and 2) assess the feasibility of the proposed Wellness Pathway for lower-income urban-dwelling older adults of color.

Methods

We administered surveys and conducted a pre-post analysis among participants enrolled in any 1 of 3 MPC-based EBPs (n=53). To assess feasibility of the pathway, we analyzed survey data and interviews (EBP participants, MPC staff, physicians, n=10).

Results

EBP participation was associated with greater disease management skills (increased time spent stretching and aerobic activity) but not improvements in self-efficacy or other health outcomes. Interviews revealed: 1) older adults valued EBPs and felt the Wellness Pathway feasible; 2) staff felt it feasible given adequate growth management; 3) physicians felt it feasible provided adequate medical facility integration.

Conclusions

MPC-based EBPs were associated with improvements in disease management skills among older adults; a proposed Wellness Pathway shows early evidence of feasibility and warrants further investigation. Future efforts to implement this model of recruiting older adults of color into EBPs should address barriers for implementation and sustainability.

Characterizing Enrollment in Observational Studies of Duchenne Muscular Dystrophy by Race and Ethnicity

Observational research benefits from inclusion of diverse cohorts. To characterize racial and ethnic diversity in observational and natural history research studies of Duchenne muscular dystrophy (DMD), highly cited and influential observational studies were identified. Fourteen United States-based articles were included. All studies cited >70% White participants with the majority having few racial minority participants. Enrollment of Black/African American individuals was particularly limited (<5% in all but one study), and Hispanic/Latino participants ranged from 3.3- 26.5% of cohorts. These results suggest a need for effective strategies to recruit, enroll, and retain racially and ethnically diverse populations into observational research in DMD.

"Maintaining hope:" challenges in counseling latino patients with advanced cancer

BACKGROUND

Latino cancer patients are at risk of poor psychological adjustment. Therapeutic effectiveness in treating Latino cancer patients with advanced cancer requires managing distress, therapeutic skill, and cultural competency. This mixed-methods study explored mental health providers' perceptions of the challenging aspects of counseling and caring for Latino patients with advanced cancer.

METHODS

Mental health providers providing services to Latino or Hispanic cancer patients received an emailed web-based survey with open- and closed-ended questions. Providers included psychiatrists, psychologists, social workers, counselors, and other mental health professionals. We invited 154 providers to participate from July 2015 to January 2017. One hundred and four accessed the survey, and 66 eligible providers responded, for a response rate of 43%. Analyses were used to explore whether clinical experience factors and training characteristics were associated with perceiving conversations about cancer (diagnosis, prognosis, and end-of-life) as challenging. Second, the challenging aspects of these conversations were explored qualitatively. Four independent coders coded responses; an inductive content analysis was utilized to analyze the data.

RESULTS

Mental health providers describe encountering many challenges in their therapeutic discussions with Latino cancer patients.

CONCLUSIONS

It is imperative to understand the factors associated with the perceived difficulty of these conversations, as well as the characteristics of these conversations, to develop culturally sensitive interventions and programs for patients and training interventions for providers.

Combined Effects of Race and Educational Attainment on Physician Visits Over 24 Years in a National Sample of Middle-Aged and Older Americans

Background

The literature on Minorities' Diminished Returns (MDRs) have shown worse than expected health of the members of racial and ethnic minority groups particularly Blacks. Theoretically, this effect can be in part due to weaker effects of educational attainment on preventive care and disease management in highly educated racial and ethnic minorities.

Objectives

The current study explored the racial and ethnic differences in the effect of baseline educational attainment on % adherance to the routine physician visits among middle-aged and older adults in the US.

Methods

This is a prospective study with 24 years of follow up. The Health and Retirement Study (HRS: 1992-2016) included 10 880 middle-aged and older adults who were Hispanic, non-Hispanic, Black or White. The independent variable was educational attainment. The dependent variable was adherance to the routine physician visits (%). Age, gender, marital status, income, health behaviors (smoking and drinking) and health (depression, self-rated health, and chronic diseases) were the covariates. Race and ethnicity were the focal moderators. Linear regression was used for data analysis.

Results

Overall, higher educational attainment was associated with higher % of adherance to the routine physician visits over the course of follow-up, net of all confounders. Race showed a significant statistical interaction with educational attainment suggesting of a smaller effect of high education attainment on % adherance to the routine physician visits for Black than White middle-aged and older adults. A similar interaction could not be found for the comparison of Hispanic and non-Hispanic middle-aged and older adults.

Conclusion

Educational attainment is associated with a larger increase in preventive and disease management doctor visits for White than Black middle-aged and older adults. This is a missed opportunity to improve the health of highly educated middle-aged and older adults. It is not race/ethnicity or class that shapes health behaviors but race/ethnicity and class that shape people's pro-health behaviors. At least some of the racial health disparities is not due to low SES but diminished returns of SES.

Sickle-Cell Disease Co-Management, Health Care Utilization, and Hydroxyurea Use

BACKGROUND

Sickle-cell disease (SCD) causes significant morbidity, premature mortality, and high disease burden, resulting in frequent health care use. Comanagement may improve utilization and patient adherence with treatments such as Hydroxyurea. The purpose of this study was to describe acute-care utilization in Medicaid-enrolled patients with SCD, patient factors associated with comanagement, and adherence to Hydroxyurea.

METHODS

Data from 2790 patients diagnosed with SCD, age 1 to 65+ years, enrolled at least 1 month in North Carolina Medicaid between March 2016 and February 2017, were analyzed. Outpatient visits were categorized as primary care, hematologist, and nonhematologist specialist. Nurse practitioners or physician assistants with unidentified specialty type or family practice were categorized separately. Comanagement was defined as a minimum of 1 primary care and 1 hematologist visit/patient during the study period.

RESULTS

There were notable age-related differences in utilization of health care services. Only 34.82% of the sample was comanaged. Comanagement was higher in the 1-to-9-year-old (44.88%) and 10-to-17-year-old groups (39.22%) versus the 31-to-45-year-old (30.26%) and 65+-year-old (18.75%) age groups. Age had the greatest influence (AUC = 0.599) on whether or not a patient was comanaged. Only a third of the sample (32.24%) had at least 1 Hydroxyurea (HU) prescription. Age was the most predictive factor of good HUadherence (AUC = 0.6503). Prediction by comanagement was minimal with an AUC = 0.5615.

CONCLUSION

Comanagement was a factor in predicting HUadherence, but further studies are needed to identify the frequency and components of comanagement needed to increase adherence and reduce acute care utilization.

Primary Care Provider Understanding of Hair Care Maintenance as a Barrier to Physical Activity in African American Women

INTRODUCTION

African American (AA) women have reported hair maintenance as a barrier to regular exercise; however, to our knowledge, this study is the first to identify primary care provider thoughts, attitudes, beliefs, and knowledge regarding hair as a barrier to increased physical activity among AA females.

METHODS

A 13-question electronic survey was sent via email to 151 clinicians working within a department of family medicine's 8 ambulatory clinics within a large urban academic medical center.

RESULTS

A total of 62 primary care clinicians completed the survey, which is a response rate of 41%. The vast majority of respondents (95%) sometimes/often engage in discussions with AA female patients regarding physical activity. However, 76% of respondents have never included a hairstyling or maintenance assessment in that discussion and only 34% noted being comfortable discussing this topic. Among a list of potential barriers to exercise, hair maintenance/scalp perspiration was rarely endorsed as important by clinicians.

DISCUSSION

This study highlights a need for increased education among primary care providers regarding AA hair care and maintenance practices as a barrier to increased physical activity in AA women. If specific barriers to increasing healthy habits among AA women are to be addressed, there must be a baseline knowledge of hair care and maintenance barriers, an understanding of the strong influence of cultural norms and practices as it relates to physical activity and exercise, and an increased comfortability when engaging in difficult cross-cultural conversations to ultimately improve health outcomes in AA females.

Transgender And Cisgender US Veterans Have Few Health Differences

Transgender people have been able to serve openly in the military since June 2016. However, the administration of President Donald Trump has signaled its interest in reinstating a ban on transgender military service. In March 2018 President Trump issued a revised memorandum that stated, in part, that people with a "history or diagnosis of gender dysphoria" who "may require substantial medical treatment, including medications and surgery-are disqualified from military service except under certain limited circumstances." Whether and how the health of transgender service members differs from that of cisgender service members (that is, those who identify with their sex assigned at birth) is largely unknown. This study used population-level data for 2014-16 from the Behavioral Risk Factor Surveillance System to compare the health of transgender and cisgender veterans and civilians. An estimated 0.5 percent of veterans in the sample identified themselves as transgender. While transgender civilians had worse health than cisgender civilians across most indicators, very few differences existed among veterans. However, transgender veterans had higher odds of having at least one disability compared to cisgender veterans, despite similar levels of access to health care. These findings largely suggest that transgender veterans do not have worse health than cisgender veterans.

A Successful Walk-In Psychiatric Model for Integrated Care

PURPOSE

Accommodating walk-in psychiatry visits in primary care can improve access to psychiatric care for patients from historically underserved groups. We sought to determine whether a walk-in psychiatry model embedded within an integrated care practice could be sustained over time, and to characterize the patients who accessed care through it.

METHODS

We reviewed electronic health records linked to 811 psychiatry encounters in an integrated care practice between October 1, 2015 and September 30, 2017. Primary outcomes were the initial and return psychiatry encounters per month. Secondary outcomes were the demographics and diagnoses of patients who accessed their initial visits through walk-in sessions and scheduled appointments.

RESULTS

490 initial psychiatry evaluations and 321 return encounters took place over the 2-year study period. The volume of initial psychiatry evaluations per month did not significantly change, but the volume of psychiatry follow-up encounters significantly increased after the walk-in session expanded. Medicaid recipients (OR, 1.9; 95% CI, 1.2 to 3.0); individuals without a college degree (OR, 1.7; 95% CI, 1.1 to 2.5); individuals who were single, divorced, or separated (OR, 1.7; 95% CI, 1.1 to 2.5); and individuals who identified as Black or Hispanic (OR, 2.5; 95% CI, 1.7 to 3.6) were more likely to access an initial psychiatry evaluation through a walk-in session as opposed to a scheduled appointment.

CONCLUSIONS

Providing psychiatric care on a walk-in basis in integrated care is sustainable. Patients from historically underserved groups may access psychiatric care disproportionately through a walk-in option when it is available.

A Systematic Review Of The Food And Drug Administration's 'Exception From Informed Consent' Pathway

In 1996 the Food and Drug Administration (FDA) created an "exception from informed consent" (EFIC) pathway for trials conducted on people incapacitated by life-threatening conditions with a therapeutic time window too narrow for reliable surrogate consent. The goals were to promote therapeutic innovation and encourage rigorous but ethical experimentation on this vulnerable population. To evaluate outcomes of this pathway, we reviewed the complete FDA docket of EFIC trials from the past two decades, encompassing forty-one trials. Among the 46,964 patients included in this review, ninety-six percent were enrolled without consent, and fewer than 1 percent withdrew before the primary endpoint. Two (8 percent) of the twenty-four superiority trials demonstrated a benefit from the experimental interventions. Many interventions were associated with adverse effects, including increased mortality, neurological deficits, and myocardial infarctions. Nearly one-third of US patients in EFIC trials were African American. While EFIC trials have yielded medical advances, investigators in future trials must pay better attention to managing withdrawals and ensuring fair demographic representation.

Sources and Impact of Time Pressure on Opioid Management in the Safety-Net

PURPOSE

This study sought to understand clinicians' and patients' experience managing chronic noncancer pain (CNCP) and opioids in safety-net primary care settings. This article explores the time requirements of safer opioid prescribing for medically and socially complex patients in the context of safety-net primary care.

METHODS

We qualitatively interviewed 23 primary care clinicians and 46 of their patients with concurrent CNCP and substance use disorder (past or current). We also conducted observations of clinical interactions between the clinicians and patients. We transcribed, coded, and analyzed interview and clinical observation recordings using grounded theory methodology.

RESULTS

Clinicians reported not having enough time to assess patients' CNCP, functional status, and risks for opioid misuse. Inadequate assessment of CNCP contributed to tension and conflicts during visits. Clinicians described pain conversations consuming a substantial portion of primary care visits despite patients' other serious health concerns. System-level constraints (eg, changing insurance policies, limited access to specialty and integrative care) added to the perceived time burden of CNCP management. Clinicians described repeated visits with little progress in patients' pain or functional status due to these barriers. Patients acknowledged clinical time constraints and reported devoting significant time to following new opioid management protocols for CNCP.

CONCLUSIONS

Time pressure was identified as a major barrier to safer opioid prescribing. Efforts, including changes to reimbursement structures, are needed to relieve time stress on primary care clinicians treating medically and socially complex patients with CNCP in safety-net settings.

Uniting the Vision for Health Equity through Partnerships: The 2nd Annual Dr. Elijah Saunders & Dr. Levi Watkins Memorial Lecture

Minority health research focuses on outcomes by race and ethnicity categories used in the United States census. Overall mortality has decreased significantly for African Americans, Latinos, and Asians over the past 20 years even though it has stopped improving for poor Whites and continues to increase for American Indians/Alaska Natives. Prevention and treatment of cardiovascular disease partly account for this trend, but there is room for improvement. Health disparities research also includes persons of less privileged socioeconomic status, underserved rural residents, and sexual and gender minorities of any race and ethnicity when the outcomes are worse than a reference population. Understanding mechanisms that lead to health disparities from behavioral, biological, environmental and health care perspectives will lead to interventions that reduce these disparities and promote health equity. Experiences with racism and discrimination generate a chronic stress response with measurable effects on biological processes and study is needed to evaluate long-term effects on health outcomes. A clinical example of effective approaches to reducing disparities is management of hypertension to promote stroke reduction that requires health system changes, patient-clinician partnerships and engagement of community organizations. Clinicians in health care settings have the potential to promote health equity by implementing standardized measures of social determinants, leveraging the power of health information technology, maximizing cultural competence and socially precise care and engaging communities to reduce health disparities. Strategic partnerships between health care institutions and community-based organizations need to parallel patient-clinician partnerships and are essential to promote health equity and reduce disparities.

Stakeholder Perspectives on the Social Determinants of Mental Health in Community Coalitions

Objective

Although evidence supports the potential for community coalitions to positively address social determinants of mental health, little is known about the views of stakeholders involved in such efforts. This study sought to understand county leaders' perspectives about social determinants related to the Health Neighborhood Initiative (HNI), a new county effort to support community coalitions.

Design

Descriptive, qualitative study, 2014.

Setting

Community coalitions, located in a large urban city, across eight service planning areas, that serve under-resourced, ethnic minority populations.

Procedures

We conducted key informant interviews with 49 health care and community leaders to understand their perspectives about the HNI. As part of a larger project, this study focused on leaders' views about social determinants of health related to the HNI. All interviews were audio-recorded and transcribed. An inductive approach to coding was used, with text segments grouped by social determinant categories.

Results

County leaders described multiple social determinants of mental health that were relevant to the HNI community coalitions: housing and safety, community violence, and employment and education. Leaders discussed how social determinants were interconnected with each other and the need for efforts to address multiple social determinants simultaneously to effectively improve mental health.

Conclusions

Community coalitions have an opportunity to address multiple social determinants of health to meet social and mental health needs of low-resourced communities. Future research should examine how community coalitions, like those in the HNI, can actively engage with community members to identify needs and then deliver evidence-based care.

Voices from Minority Youth on Help-Seeking and Barriers to Mental Health Services: Partnering with School-Based Health Centers

Objective

Schools and school-based health centers (SBHCs) play an important role in reducing disparities in access to mental health treatment. However, there is a need to increase student engagement in school mental health services. This study sought to understand the perceptions of low-income minority youth on help-seeking and barriers to mental health services at SBHC sites.

Setting

A network of SBHCs, called Wellness Centers, developed as part of a strategic plan to serve students and community members in under-resourced areas of a large urban school district.

Participants and Procedures

We conducted focus groups with 76 middle and high school students at nine SBHC sites through a community-academic partnered approach from January to May 2014. The focus groups were audio-recorded, transcribed, and major themes coded with Atlas.ti.5.1.

Results

Students identified teachers as a primary source of support for mental health issues, followed by peers and mental health counselors. Students felt that trust and connection were vital for help-seeking. Barriers to using SBHCs included: embarrassment; fear of judgment; concerns about confidentiality; a sense that they should keep things inside; and lack of awareness.

Conclusions

Despite the resources available at SBHCs, students face barriers to help-seeking. SBHCs can help teachers and school staff gain awareness of mental health issues and services available to students. The students' recommendations-making SBHCs more comfortable, raising mental health awareness, and bolstering connections with school and SBHC staff-may improve engagement in mental health services at schools with SBHCs.

California And The Changing American Narrative On Diversity, Race, And Health

The historical narrative on diversity, race, and health would predict that California's population change from 22 percent racial/ethnic minority in 1970 to 62 percent in 2016 would lead to a massive health crisis with high mortality rates, low life expectancy, and high infant mortality rates-particularly given the state's high rates of negative social determinants of health: poverty, high school incompletion, and uninsurance. We present data that suggest an alternative narrative: In spite of these negative factors, California has very low rates of mortality and infant mortality and long life expectancy. This alternative implies that racial diversity may offer opportunities for good health outcomes and that community agency may be a positive determinant. Using national-level mortality data on racial/ethnic groups, we suggest that new theoretical models and methods be developed to assist the US in achieving high-level wellness as it too becomes "majority minority."

Confronting The Effects Of Climate Change On Health In California

Vulnerable communities have been forced to address the deepening impact of severe weather events on residents' well-being.