Feasibility of Remote Blood Pressure Monitoring for Detection and Management of Maternal Hypertension in a predominantly Black, Rural and Medicaid Population in Mississippi

Background: Remote patient monitoring (RPM) has potential in hypertension management, but limited studies have focused on maternal hypertension, especially among vulnerable populations. The objective of this study was to integrate RPM into perinatal care for pregnant patients at elevated risk of hypertensive disorders to show feasibility, acceptability, and safety. Methods: A prospective pilot cohort study was conducted at the University of Mississippi Medical Center 2021-2023. Participants' blood pressure readings were remotely captured and monitored until 8-week postpartum, with timely assessment and intervention. Results: Out of 98 enrollees, 77 utilized RPM, and no maternal or neonatal deaths occurred within 60-day postpartum. High program satisfaction was reported at discharge. Conclusion: This study demonstrates the feasibility and acceptability of RPM for perinatal care in a vulnerable population. Positive outcomes were observed, including high patient satisfaction and no maternal or neonatal deaths. Further research should address patient engagement barriers and develop tailored protocols for improved clinical outcomes.

Recruitment strategies in marginalized industries for occupational health research: an example in a pilot study of cleaning staff during COVID-19

This commentary describes challenges in recruiting workers from marginalized industries with examples from a pilot study of janitors, custodians, and maids and their experiences of cleaning and disinfection protocols during COVID-19 and potentially associated respiratory symptoms. Recruitment strategies included contacting a local hospital, national workers' unions, and a large Arizona employer; using online Facebook groups; and contacting Arizona maid service companies and a school district. English and Spanish online and hard copy surveys about cleaning protocols and respiratory symptoms were used. Participants could also participate in online/phone interviews. Worker's compensation, liability, and confidentiality were concerns across organizations. Online surveys yielded unreliable data. Hard copy surveys were used due to workers' limited technology access. We reflect upon these challenges and discuss other strategies for recruiting from marginalized populations for occupational health research. Building trust with organizations and workers and considering technology access may ultimately increase recruitment feasibility.

Manhattan Vision Screening and Follow-up Study (NYC-SIGHT): Vision and refractive error results

CLINICAL RELEVANCE

Optometrists can play a key role in providing access to eye care in underserved populations by organising community-based eye health screenings that include optometric exams to detect vision impairment and uncorrected refractive error.

BACKGROUND

Community-based eye health screenings and optometric exams were conducted in the NYC-SIGHT Study.

METHODS

A sub-analysis of vision impairment and refractive error results within a 5-year prospective, cluster-randomised clinical trial. Eligible individuals (age ≥40 years) were recruited from 10 affordable housing developments in Upper Manhattan. Developments were randomised into usual care (received glasses prescription only) and intervention (free glasses) groups. Participants with 6/12 visual acuity or worse, intraocular pressure 23-29 mmHg, or an unreadable fundus image were scheduled with the study optometrist for refraction and a non-dilated exam. Visual improvement data were obtained by comparing the presenting acuity at screening compared to the best corrected acuity after refraction by the optometrist. Chi-square, two-sample t-tests, and a stepwise multivariate logistic regression model were used to determined factors associated with improvable visual impairment.

RESULTS

Seven hundred and eight participants completed screening, 308 received an optometric exam. Those with improvable vision impairment (n = 251), mean age: 69.8 years, 70.5% female, 53% African American, 39.8% Hispanic, >95% had health insurance. Refractive error diagnosed in 87.8% of the participants; lines of improvement: 2 lines (n = 59), 3 to 5 lines (n = 120), and ≥6 lines (n = 72). Stepwise multivariate logistic regression analysis showed that participants with visual acuity 6/12 or worse (odds ratio 16.041, 95% confidence interval 6.009 to 42.822, p = 0.000) or a normal fundus image (odds ratio 2.783, 95% confidence interval 1.001 to 7.740, p = 0.05) had significantly higher odds of improvable vision impairment.

CONCLUSION

This innovative, targeted community-based study included an optometrist who detected high rates of refractive error and improvable vision impairment in an underserved population living in New York City.

Large-Scale, Primary Care-Based Hepatitis C Treatment in an Urban, Medically Underserved Patient Population

Hepatitis C virus (HCV) infection is a critical public health concern in the United States. HCV is highly curable, but access to care is limited for many patients. Primary care models can expand access to HCV care. The Grady Liver Clinic (GLC) is a primary care-based HCV clinic founded in 2002. During 20 years, using a multidisciplinary team, the GLC expanded its operations in response to advances in HCV screening and treatment. We describe the clinic model, patient population, and treatment outcomes of the clinic from 2015 through 2019. During this period, 2689 patients were seen in the GLC, and 77% (n = 2083) initiated treatment. Eighty-five percent (1779 of 2083) of patients who started treatment completed treatment and were tested for cure, and 1723 (83% of the total treated cohort, 97% of those tested for cure) were cured. Building on a successful primary care-based treatment model, the GLC dynamically responded to the changes in HCV screening and treatment guidelines, continually increasing access to HCV care. The GLC serves as a model of primary care-based HCV care that aims to achieve HCV microelimination in a safety-net health system. Our findings support the notion that for the United States to achieve elimination of HCV by 2030, generalists can and should provide HCV care, particularly in medically underserved patient populations.

Precision therapy for a medically actionable ATP1A3 variant from a genomic medicine program in an underserved population

BACKGROUND

Genomic medicine is revolutionizing the diagnosis of rare diseases, but the implementation has not benefited underrepresented populations to the same degree. Here, we report the case of a 7-year-old boy with hypotonia, global developmental delay, strabismus, seizures, and previously suspected mitochondrial myopathy. This proband comes from an underrepresented minority and was denied exome sequencing by his public insurance.

METHODS

After informed consent was obtained, buccal cells from the proband were collected and whole exome sequencing was performed. Illumina Dragen and Emedgene software was used to analyze the data at Baylor Genetics. The variants were further intepreted according to ACMG guidelines and the patient's phenotype.

RESULTS

Through whole-exome sequencing (WES) under the Community Texome project, he was found to have a heterozygous de novo pathogenic variant in the ATP1A3 gene located on chromosome 19q13.

CONCLUSION

In retrospect, his symptomatology matches the known medical conditions associated with the ATP1A3 gene namely Alternating Hemiplegia of Childhood 2 (AHC), a rare autosomal dominant disorder with an incidence of 1 in one million. His single nucleotide variant, (c.2401G>A, p.D801N), is predicted to be damaging. The specific amino acid change p.D801N has been previously reported in ClinVar along with the allelic variant p.D801Y and both are considered pathogenic. The identification of this variant altered medical management for this patient as he was started on a calcium antagonist and has reported no further hemiplegic episodes. This case illustrates the value of implementing genomic medicine for precision therapy in underserved populations.

Telehealth Use During the COVID-19 Pandemic Among Veterans and Nonveterans: Web-Based Survey Study

BACKGROUND

In the first year of the COVID-19 pandemic, studies reported delays in health care usage due to safety concerns. Delays in care may result in increased morbidity and mortality from otherwise treatable conditions. Telehealth provides a safe alternative for patients to receive care when other circumstances make in-person care unavailable or unsafe, but information on patient experiences is limited. Understanding which people are more or less likely to use telehealth and their experiences can help tailor outreach efforts to maximize the impact of telehealth.

OBJECTIVE

This study aims to examine the characteristics of telehealth users and nonusers and their reported experiences among veteran and nonveteran respondents.

METHODS

A nationwide web-based survey of current behaviors and health care experiences was conducted in December 2020-March 2021. The survey consisted of 3 waves, and the first wave is assessed here. Respondents included US adults participating in Qualtrics web-based panels. Primary outcomes were self-reported telehealth use and number of telehealth visits. The analysis used a 2-part regression model examining the association between telehealth use and the number of visits with respondent characteristics.

RESULTS

There were 2085 participants in the first wave, and 898 (43.1%) reported using telehealth since the pandemic began. Most veterans who used telehealth reported much or somewhat preferring an in-person visit (336/474, 70.9%), while slightly less than half of nonveterans (189/424, 44.6%) reported this preference. While there was no significant difference between veteran and nonveteran likelihood of using telehealth (odds ratio [OR] 1.33, 95% CI 0.97-1.82), veterans were likely to have more visits when they did use it (incidence rate ratio [IRR] 1.49, 95% CI 1.07-2.07). Individuals were less likely to use telehealth and reported fewer visits if they were 55 years and older (OR 0.39, 95% CI 0.25-0.62 for ages 55-64 years; IRR 0.43, 95% CI 0.28-0.66) or lived in a small city (OR 0.63, 95% CI 0.43-0.92; IRR 0.71, 95% CI 0.51-0.99). Receiving health care partly or primarily at the Veterans Health Administration (VA) was associated with telehealth use (primarily VA: OR 3.25, 95% CI 2.20-4.81; equal mix: OR 2.18, 95% CI 1.40-3.39) and more telehealth visits (primarily VA: IRR 1.5, 95% CI 1.10-2.04; equal mix: IRR 1.57, 95% CI 1.11-2.24).

CONCLUSIONS

Telehealth will likely continue to be an important source of health care for patients, especially following situations like the COVID-19 pandemic. Some groups who may benefit from telehealth are still underserved. Telehealth services and outreach should be improved to provide accessible care for all.

Addressing barriers to accessing family planning services using mobile technology intervention among internally displaced persons in Abuja, Nigeria

BACKGROUND

Inadequate access to sexual and reproductive health services is prevalent among women of reproductive age in internally displaced people's camps. To address this, we implemented a mobile technology intervention, known as the Linking Underserved Populations to Sexual and Reproductive Health Services, in the Wassa Internally Displaced People's camp, Abuja, Nigeria.

OBJECTIVE

This study aimed to assess the impact of the Linking Underserved Populations to Sexual and Reproductive Health Services Intervention in improving sexual and reproductive health services among women of reproductive age in Wassa Internally Displaced People's camp.

STUDY DESIGN

A baseline survey was conducted among 105 women of reproductive age in the Wassa camp, followed by the deployment of the Linking Underserved Populations to Sexual and Reproductive Health Services intervention, which delivered family planning messages to camp residents between September 2020 and June 2021. This was followed by an endline survey. The FP utilization data in the camp health post were mined during the period of the intervention and were analyzed using Stata version 15 with a chi-square test performed at a significance level of 5%.

RESULTS

Awareness of family planning among women of reproductive age in Wassa camp increased from 54.2% at baseline to 98% at endline. The major reason for refusal of family planning at baseline, which was a lack of spousal consent reduced from 29.5% to 7% at endline. Contraceptive prevalence rate increased from 18.1% at baseline to 26.2% at endline. In addition, 133 new family planning users were recorded at the endline. The uptake of family planning services recorded a strong association with family planning consultations (P<.05; χ2=6.41) and receipt of bulk short message service (P<.05; χ2=4.90).

CONCLUSION

Mobile technology interventions are a recommended strategy that can increase family planning awareness and address barriers to family planning uptake.

Efficacy of a Brief Mindfulness Intervention in Underserved Individuals Receiving Inpatient Treatment for Opioid Use Disorder: A Pilot Study

Introduction A mindfulness intervention is a mind-body complementary health approach that focuses on the relationships between mind, body, brain, and behavior. Mindfulness-Based Stress Reduction (MBSR) and similar mindfulness programs have been shown to decrease drug craving and relapse and improve emotional regulation, stress, pain, and anxiety. To our knowledge, a very limited number of studies have examined its efficacy in individuals from underserved populations. Underserved populations experience disparities in healthcare access, and as a result, see poorer addiction-related outcomes. The goal of this pilot study was to utilize an evidence-based, neuroscience-informed brief mindfulness intervention to improve mental health and decrease substance use behavior in a vulnerable, underserved population in New Jersey suffering from opioid use disorder (OUD). Methods We implemented a brief MBSR intervention in 15 underserved individuals undergoing inpatient medication-assisted treatment (MAT) for OUD. Individuals received weekly intervention sessions lasting one hour over six weeks. Furthermore, they practiced mindfulness for 10 minutes daily. Participants completed pre-and post-mindfulness intervention surveys to examine their mental well-being, drug craving, perceived stress, and emotional regulation. Results Within-subjects t-test results showed that compared to pre-intervention, participants showed significantly decreased perceived stress (t(14) =2.401, p=.015) and significantly decreased difficulty in emotional regulation (t(13) =3.426, p=.002 ) at post-intervention. They also showed significantly decreased drug craving post-intervention (t(14) =5.501, p=.<001). Anxiety decreased post-intervention but was not statistically significant (t(14) =1.582, p=.068). Conclusion This pilot study demonstrates that a brief mindfulness intervention can be effective for underserved individuals with OUD. Consistent with our hypothesis, results showed that a six-week mindfulness intervention could reduce everyday stress, drug craving, and difficulties in emotional regulation. In the future, a large-scale randomized control trial should be conducted with a control group to demonstrate the efficacy of this useful intervention.

VaxForce: Mobilizing interprofessional licensees and students for community COVID-19 vaccination events

During the early phases of the COVID-19 vaccine efforts, there was limited supply of the vaccine available to administer. However, as the vaccine supply improved, there was a lack of qualified personnel to administer the vaccine. VaxForce, a volunteer workforce management system to vet healthcare professionals and students and match them with existing vaccination events, was created. VaxForce activities were mainly focused on under-resourced communities. From March 2021 through July 2022, VaxForce mobilized 316 health professional volunteers in 72 vaccination events administering over 8451 vaccines in 7 counties in California. The racial and ethnic profile of vaccine recipients in VaxForce events were reported to be 49% Latinx, 26% Black, 4% Asian/Pacific Islander, 18% White, 3% Mixed Race.

The Effectiveness of an After-school Sport Sampling Intervention on Urban Middle School Youth in the Midwest: Posttest-Only Study

BACKGROUND

Effective and scalable interventions are needed to combat chronic low levels of youth physical activity. After-school sport sampling programs may be vital interventions for teaching sports and increasing physical literacy and physical activity, which result in healthy lifelong habits that are maintained into adulthood.

OBJECTIVE

The purpose of this study was to test the effectiveness of an after-school sport sampling intervention among underserved youth in the Midwest.

METHODS

Youth (n=81) in 3 middle schools within a large Midwest city participated in an 8-month, after-school physical activity intervention that aimed to increase moderate- and vigorous-intensity physical activity, improve physical literacy, and decrease BMI. Difference scores for this 2-group, posttest-only design were calculated. A series of 2-tailed t tests were conducted to assess between-group differences.

RESULTS

The intervention group had significantly better physical literacy (t₁₁₅=7.57; P=.004) and engaged in more moderate- and vigorous-intensity physical activity minutes per week (t₁₁₅=4.28; P=.04) and steps per day (t₁₁₅=4.29; P=.03).

CONCLUSIONS

An after-school sport sampling program may be an effective solution for combating youth physical inactivity. Future research should assess the scalability of this intervention with larger populations and in different areas.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/37126.

Breast and cervical cancer screening rates in student-run free clinics: A systematic review

OBJECTIVE

To assess rates of breast and cervical cancer screening at student-run free clinics to understand challenges and strategies for advancing quality and accessibility of women's health screening.

METHODS

The authors performed a systematic search of publications in Ovid MEDLINE, PubMed, Web of Science, and Google Scholar databases from database inception to 2020. English-language publications assessing rates of breast and cervical cancer screening in student-run free clinics were included. Structured data extraction was completed for each publication by two reviewers independently. Risk of bias was assessed using a modified Agency for Healthcare Research and Quality checklist. Results were synthesized qualitatively because of study heterogeneity.

RESULTS

Of 3634 references identified, 12 references met study inclusion criteria. The proportion of patients up-to-date on breast cancer screening per guidelines ranged from 45% to 94%. The proportion of patients up-to-date on cervical cancer screening per guidelines ranged from 40% to 88%.

CONCLUSION

Student-run free clinics can match breast and cervical cancer screening rates among uninsured populations nationally, although more work is required to bridge the gap in care that exists for the underinsured and uninsured.

Raising Capacity to Address Mental Health Concerns in Costa Rica

Background A family medicine team based out of Mayo Clinic, Rochester assembled in 2019 to provide home visits and direct care to underserved populations of patients in La Cruz, Costa Rica. In addition to the provision of direct patient care, our team was interested in conducting a community needs-based assessment to identify an area for provider education efforts and the local providers on a chronic health issue using local feedback and physician data. Suicide awareness and prevention were identified as a priority based on rising suicide rates as well as limited psychiatry services in the area, with some major providences having ~0.60 psychiatrists available per 100,000 people. Our group provided a half-day educational course on mental health topics related to suicide awareness for local health workers. The primary objective of this study was to evaluate any lasting changes in practice, confidence, and knowledge among local health workers attributable to our training and add to the limited research on this topic. Methods Two groups of participants (81) from local hospitals were recruited via local providers and divided into two morning and afternoon groups on a single day. Each group comprised primary care providers, nurses, social workers, and finance officers. Both were given the same educational presentation that could be broadly applied to each various role. Our team provided lectures on mental health, as well as how to improve personal resilience. Locally medically trained translators were used. Pre and post-lecture surveys gathered demographic data, experience with these mental health issues, and confidence in addressing mental health concerns. Pre and post-lecture surveys, including open-ended as well as Likert scale and multiple-choice questions, were handed out at the beginning and end of each lecture to all participants. A four to six months follow-up survey was delivered by email using SurveyMonkey to evaluate retention and impact of educational materials. Results The initial two groups of participants (n = 81) were aged 23-60 years (mean: 43), and 67% (39) were female. Work experience ranged from 0 to 37 years (mean: 14) with 64% (37) doing direct patient care. Preliminary lecture content data from participants (n = 44) demonstrated an overall increase in correct responses by +15.4% from the pre-test (percent correct, 38.1%) to post-test (53.5%, p < 0.01). Individuals (n = 55) with past exposure to suicide were much more likely to report asking patients about suicide than those with no prior exposure (56.3% vs. 8.3%; p < 0.01). At the six-month follow-up with participants (n = 11), when asked about their confidence in learning objectives from the lecture given prior, the rates of low confidence decreased as well as the level of high confidence improved but was not statistically significant. The rate of low confidence of respondents' confidence in asking about mental health concerns decreased from 35.2% to 0% (p < 0.01). Conclusions Our group was able to successfully deliver lectures to a mixed audience of health workers in a region self-identified as struggling with mental health issues in Costa Rica. The surveys suggested learning occurred. A trend suggestive that the educational content improved the participants' confidence and knowledge components over time was noted. Future service trips may be able to build on this initial experience to improve on ways to raise capacity while delivering direct care to regions in need.

"In Class We Were All One." A Qualitative Exploration of Yoga and Educational Interventions for Predominantly Low-Income and Minority Adults with Chronic Low Back Pain

Introduction: Chronic low back pain (cLBP) can be physically and psychologically debilitating and disproportionally afflicts vulnerable populations. Yoga and education are increasingly common interventions for cLBP yet are understudied in low-income and minority adults. The objective of this qualitative study was to understand the yoga and self-care experience of adults with cLBP from urban, underserved communities who were enrolled in a randomized controlled trial that included these treatments. Methods: We interviewed 26 (18 yoga and 8 education) participants. Interviews were transcribed verbatim and analyzed using thematic analysis with codes developed inductively from data. Results: Participants from both yoga and education groups reported initial apprehension and ambivalence toward their respective intervention. However, physical and psychological benefits were noted, mainly in the form of improved pain self-management. Communal support and camaraderie reported by the yoga group was absent and desired by education participants. Social factors impeding the ability to sustain yoga practice included transportation, access, and cost, whereas education participants described literacy and language challenges and a general lack of motivation to read the book. Conclusion: Yoga and education are viable treatments for adults with cLBP who live in underserved neighborhoods. However, social stigma and socioeconomic barriers may hinder their uptake. Communal support in group-based nonpharmacological treatments is valued and may contribute to participation and clinical outcomes. ClinicalTrials.gov Identifier: NCT01343927.

Transitioning to Remote Recruitment and Intervention: A Tale of Two Palliative Care Research Studies Enrolling Underserved Populations During COVID-19

CONTEXT

During the COVID-19 pandemic, community-based research studies experienced prolonged shutdowns unless able to pivot to remote study procedures.

OBJECTIVES

To describe the revision of two National Institutes of Health funded community-based palliative-focused clinical trials serving underserved populations to accommodate remote subject enrollment and examine its impact.

METHODS

Transitioning to remote processes required multiple protocol and procedural changes including: altering informed consent processes; reducing the number of surveys administered; adding internet access as an inclusion criterion. To understand technological challenges, a screening tool was developed for one study to identify potentially eligible subjects' technology abilities and accessibility.

RESULTS

Subjects' limited access to the internet and internet-enabled devices and discomfort with technology led to changes in recruitment patterns. Lack of familiarity with technology increased the amount of time it took research team members and subjects to connect remotely. Patients with significant cognitive and/or sensory deficits were at higher risk of experiencing fatigue during remote study visits leading to streamlining of data collection. A researcher-developed technology screening tool found that potential subjects were not comfortable with videoconferencing through Zoom expressing a preference for phone visits. Reduced travel time made scheduling remote study visits more efficient.

CONCLUSION

Future community- and home-based palliative care trials must consider the best way to utilize remote recruitment, enrollment, and data collection processes to increase efficiency and reduce costs. Researchers should consider technology accessibility and train staff to ensure the greatest possible opportunity to recruit underserved populations who have traditionally been underrepresented in research studies.

Assessing a Smartphone App (AICaries) That Uses Artificial Intelligence to Detect Dental Caries in Children and Provides Interactive Oral Health Education: Protocol for a Design and Usability Testing Study

BACKGROUND

Early childhood caries (ECC) is the most common chronic childhood disease, with nearly 1.8 billion new cases per year worldwide. ECC afflicts approximately 55% of low-income and minority US preschool children, resulting in harmful short- and long-term effects on health and quality of life. Clinical evidence shows that caries is reversible if detected and addressed in its early stages. However, many low-income US children often have poor access to pediatric dental services. In this underserved group, dental caries is often diagnosed at a late stage when extensive restorative treatment is needed. With more than 85% of lower-income Americans owning a smartphone, mobile health tools such as smartphone apps hold promise in achieving patient-driven early detection and risk control of ECC.

OBJECTIVE

This study aims to use a community-based participatory research strategy to refine and test the usability of an artificial intelligence-powered smartphone app, AICaries, to be used by children's parents/caregivers for dental caries detection in their children.

METHODS

Our previous work has led to the prototype of AICaries, which offers artificial intelligence-powered caries detection using photos of children's teeth taken by the parents' smartphones, interactive caries risk assessment, and personalized education on reducing children's ECC risk. This AICaries study will use a two-step qualitative study design to assess the feedback and usability of the app component and app flow, and whether parents can take photos of children's teeth on their own. Specifically, in step 1, we will conduct individual usability tests among 10 pairs of end users (parents with young children) to facilitate app module modification and fine-tuning using think aloud and instant data analysis strategies. In step 2, we will conduct unmoderated field testing for app feasibility and acceptability among 32 pairs of parents with their young children to assess the usability and acceptability of AICaries, including assessing the number/quality of teeth images taken by the parents for their children and parents' satisfaction.

RESULTS

The study is funded by the National Institute of Dental and Craniofacial Research, United States. This study received institutional review board approval and launched in August 2021. Data collection and analysis are expected to conclude by March 2022 and June 2022, respectively.

CONCLUSIONS

Using AICaries, parents can use their regular smartphones to take photos of their children's teeth and detect ECC aided by AICaries so that they can actively seek treatment for their children at an early and reversible stage of ECC. Using AICaries, parents can also obtain essential knowledge on reducing their children's caries risk. Data from this study will support a future clinical trial that evaluates the real-world impact of using this smartphone app on early detection and prevention of ECC among low-income children.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/32921.

The Use of Community Health Workers in Community Health Centers

BACKGROUND

Until 2016, community health centers (CHCs) reported community health workers (CHWs) as part of their overall enabling services workforce, making analyses of CHW use over time infeasible in the annual Uniform Data System (UDS).

OBJECTIVE

The objective of this study was to examine changes in the CHW workforce among CHCs from 2016 to 2018 and factors associated with the use of CHWs.

RESEARCH DESIGN, SUBJECTS, MEASURES

The two-part model estimated separate effects for the probability of using any CHW and extent of CHW full-time equivalents (FTEs) reported in those CHCs, using a total of 4102 CHC-year observations from 2016 to 2018. To estimate the extent to which increases in CHW workforce are attributable to real growth or rather are a consequence of a change in reporting category, we also conducted a difference-in-differences analysis to compare non-CHW enabling services FTEs between CHCs with and without CHWs before (2013-2015) and after (2016-2018) the reporting change in 2016.

RESULTS

The rate of CHCs that employed CHWs rose from 20.04% in 2016 to 28.34% in 2018, while average FTEs stayed relatively flat (3.32 FTEs). Patient visit volume (larger CHCs) and grant funding (less reliant on federal but more reliant on private funding) were significant factors associated with CHW use. However, we found that a substantial portion of this growth was attributable to a change in UDS reporting categories.

CONCLUSION

While we do not address the reasons why CHCs have been slow to use CHWs, our results point to substantial financial barriers associated with CHCs' expanding the use of CHWs.

Assessment of Household Food Insecurity During a Medical Mission to Chincha, Peru

Introduction

Food insecurity directly influences health outcomes and is an important consideration for medical missions seeking to address chronic disease, particularly those serving disaster-prone communities. The region of Peru in which we held an inaugural mission is vulnerable to developing food insecurity following natural disasters. We, therefore, sought to evaluate food insecurity to understand the community’s needs and inform future public health efforts.

Methods

In this cross-sectional pilot study, a convenience sample representing the households of patients attending a student-run health fair at the community medical center in Chincha, Peru was assessed for food insecurity. An adult female (n = 30) of each randomly selected family attending the fair was asked to complete the Household Food Security Survey (HFSS) developed by the US Department of Agriculture. The survey items were aggregated into a single, continuous food security scale reflecting the severity of hunger within a household.

Results

Two-thirds of respondents (n = 20) acknowledged anxiety about having enough food at home over the past 12 months, making it the most common concern. Nearly three in five respondents were concerned about their ability to provide a balanced diet. We found that 16.7% of all households were food insecure with severe hunger, 26.7% were food insecure with moderate hunger, 30% were food insecure without hunger, and 26.7% were food secure.

Conclusion

Nearly three-quarters of families attending our clinic experience some degree of food insecurity. Families with children were disproportionately affected. The high levels of food insecurity many years after a natural disaster support the development of future social programs such as food pantries. We intend to continue our partnership in Chincha and perform the HFSS survey on a periodic basis to monitor hunger.

Status epilepticus in the Canadian Arctic: A public health imperative hidden in plain sight

Objective

The World Health Organization, International League Against Epilepsy (ILAE), and International Bureau for Epilepsy have called epilepsy a public health imperative, with appropriate emphasis on low‐to‐middle‐income countries (LMIC). Although Canada is a high‐income country (HIC), income is not distributed uniformly. Furthermore, epilepsy data from the national statistical agency explicitly overlook the Arctic by excluding these territories. A common neurologic emergency, status epilepticus (SE) is a life‐threatening manifestation of epilepsy that demands prompt treatment to avoid death and long‐term sequelae. Therefore, we examined the rate of SE in a well‐defined Canadian Arctic region.

Methods

This study takes epidemiologic advantage of the Kivalliq Region's geographical isolation, which is accessible only by air. All SE patients requiring emergency care are consistently flown 1200‐1900 kilometers to a single designated hospital in a distinct southern part of Canada for further management and electroencephalography (EEG). We conducted a retrospective database and chart review at this “bottleneck” hospital to identify patients with seizure(s) severe enough to justify emergency airborne medical evacuation over a 11.25‐year period from 2009 to 2020.

Results

We screened 40 392 EEGs to yield 117 distinct medical evacuations for “operational SE” from 99 patients to derive estimated SE incidences of 99.9 evacuations per 100 000/year and 84.5 patients per 100 000/year. The average time from seizure onset to EEG was 3.2 days. Only 16.2% of SE patients had known epilepsy. For “confirmed SE” cases meeting ILAE criteria, or cases with persistently epileptiform EEG despite days of empiric treatment, estimated incidence was 77.7 evacuations per 100 000/year and 64.9 patients per 100 000/year.

Significance

High SE and epilepsy rates in the Canadian Arctic are consistent with LMIC rather than HIC. Our findings demonstrate the paradox of LMIC‐equivalent epilepsy populations camouflaged within HIC. Our findings also highlight the long‐standing plight of these under‐served and overlooked populations hidden in plain sight.

Census Tract Patterns and Contextual Social Determinants of Health Associated With COVID-19 in a Hispanic Population From South Texas: A Spatiotemporal Perspective

BACKGROUND

Previous studies have shown that various social determinants of health (SDOH) may have contributed to the disparities in COVID-19 incidence and mortality among minorities and underserved populations at the county or zip code level.

OBJECTIVE

This analysis was carried out at a granular spatial resolution of census tracts to explore the spatial patterns and contextual SDOH associated with COVID-19 incidence from a Hispanic population mostly consisting of a Mexican American population living in Cameron County, Texas on the border of the United States and Mexico. We performed age-stratified analysis to identify different contributing SDOH and quantify their effects by age groups.

METHODS

We included all reported COVID-19-positive cases confirmed by reverse transcription-polymerase chain reaction testing between March 18 (first case reported) and December 16, 2020, in Cameron County, Texas. Confirmed COVID-19 cases were aggregated to weekly counts by census tracts. We adopted a Bayesian spatiotemporal negative binomial model to investigate the COVID-19 incidence rate in relation to census tract demographics and SDOH obtained from the American Community Survey. Moreover, we investigated the impact of local mitigation policy on COVID-19 by creating the binary variable "shelter-in-place." The analysis was performed on all COVID-19-confirmed cases and age-stratified subgroups.

RESULTS

Our analysis revealed that the relative incidence risk (RR) of COVID-19 was higher among census tracts with a higher percentage of single-parent households (RR=1.016, 95% posterior credible intervals [CIs] 1.005, 1.027) and a higher percentage of the population with limited English proficiency (RR=1.015, 95% CI 1.003, 1.028). Lower RR was associated with lower income (RR=0.972, 95% CI 0.953, 0.993) and the percentage of the population younger than 18 years (RR=0.976, 95% CI 0.959, 0.993). The most significant association was related to the "shelter-in-place" variable, where the incidence risk of COVID-19 was reduced by over 50%, comparing the time periods when the policy was present versus absent (RR=0.506, 95% CI 0.454, 0.563). Moreover, age-stratified analyses identified different significant contributing factors and a varying magnitude of the "shelter-in-place" effect.

CONCLUSIONS

In our study, SDOH including social environment and local emergency measures were identified in relation to COVID-19 incidence risk at the census tract level in a highly disadvantaged population with limited health care access and a high prevalence of chronic conditions. Results from our analysis provide key knowledge to design efficient testing strategies and assist local public health departments in COVID-19 control, mitigation, and implementation of vaccine strategies.

Initiation of an Intraoperative Radiotherapy Program at a Safety net Hospital: What Is the Impact of an Intraoperative Radiotherapy Program in Underserved Patients With Early Breast Cancer?

BACKGROUND

Intraoperative radiotherapy (IORT) can allow for single-dose radiation treatment following breast conservation therapy in low-risk patients with early breast cancer, in lieu of a traditional 6-week course of whole breast radiotherapy (WBRT). The objective of this study was to analyze the uptake and utilization of an IORT program in a safety-net hospital.

MATERIALS AND METHODS

A retrospective review was conducted for all patients who underwent IORT from September 2014 to June 2018. Patient demographics, tumor characteristics, and IORT outcomes were analyzed. The proportion of patients undergoing IORT were determined to assess utilization and uptake.

RESULTS

There were 27 female patients that received IORT, 23 (85.2%) of which required no further radiotherapy. Three (7.4%) patients had positive axillary lymph nodes and/or positive margins requiring subsequent WBRT. One patient (3.7%) developed an in-breast recurrence distant from the lumpectomy site 23 months after IORT. Ten patients (37.0%) developed a postoperative complication, including 5 seromas and 6 wound complications (superficial infections and/or wound necrosis). Overall, in the 46-month study period, IORT accounted for only 6.4% of 423 operations. Still, 27 of 29 (93.1%) patients who met eligibility criteria for IORT underwent the procedure.

DISCUSSION

Although IORT comprised only 6.4% of all cases due to higher rates of mastectomy rates and advanced disease in our population, there was a high uptake of IORT among patients who met eligibility criteria for the procedure. Major complication rates of IORT were low, and most patients successfully completed radiotherapy in 1 intraoperative dose.

Palliative Care Utilization Among Patients With COVID-19 in an Underserved Population: A Single-Center Retrospective Study

BACKGROUND

As health-care institutions mobilize resources to address the coronavirus disease 2019 (COVID-19) pandemic, palliative care may potentially be underutilized. It is important to assess the use of palliative care in response to the COVID-19 pandemic.

METHODS

This is a retrospective single-center study of patients with COVID-19 diagnosed via reverse transcriptase-polymerase chain reaction assay admitted between March 1, 2020, and April 24, 2020. An analysis of the utilization of palliative care in accordance with patient comorbidities and other characteristics was performed while considering clinical outcomes. Chi-square test was used to determine associations between categorical variables while t-tests were used to compare continuous variables.

RESULTS

The overall mortality rate was 21.5% (n = 52), and in 48% (n = 25) of these patients, palliative care was not involved. Fifty-nine percent (n = 24) of those who had palliative consults eventually elected for comfort measures and transitioned to hospice care. Among those classified as having severe COVID-19, only 40% (n = 31) had palliative care involvement. Of these patients with severe COVID-19, 68% (n = 52) died. Patients who got palliative care consults were of older age, had higher rates of intubation, a need for vasopressors, and were dead.

CONCLUSION

There was a low utilization rate of palliative care in patients with COVID-19. Conscious utilization of palliative care is needed at the time of COVID-19.

Preventive Care and Chronic Disease Management Comparison of Appalachian and Non-Appalachian Community Health Centers in the United States

Introduction

The Appalachian region is often characterized by poor health outcomes and economic depression. Health centers (HCs) are community-based and patient-directed organizations that deliver comprehensive, culturally competent, high-quality primary healthcare services in high need areas, including Appalachia, where economic, geographic, or cultural factors can hinder access to healthcare services.

Purpose

The study compares the clinical quality performance in preventive care and chronic disease management between Appalachian HCs and their non-Appalachian counterparts.

Methods

Using 2015 Uniform Data System (UDS) health center data, bivariate and multivariate linear regression analyses examine the association of Appalachian HC with performance on preventive and chronic care clinical quality measures (CQMs).

Results

In the multivariate analysis, patients served at Appalachian HCs are more likely to receive colorectal cancer screening and pediatric weight assessment and counseling than at non-Appalachian HCs. No statistically significant differences in performance observed among other CQMs. The percentage of Medicaid patients and total physician FTEs have positive associations with preventive care in colorectal and cervical cancer screening, pediatric weight assessment and counseling, and tobacco screening and cessation intervention as well as chronic disease management of aspirin therapy for ischemic vascular disease and hypertension control in the multivariate model.

Implications

Overall Appalachian HCs perform as well as or better than non-Appalachian HCs in delivering preventive and chronic care services. Further examination of clinical quality improvement programs, insurance payer mix, and practice size among Appalachian HCs could advance the replication of clinical quality success for clinics in similar underserved communities.

Characterizing Hand Infections in an Underserved Population: The Role of Diabetic Status in Antibiotic Choice and Infection Location

Introduction Patients with diabetes mellitus (DM) in underserved communities are at greater risk for hand infections. We aimed to describe the features of hand infections presenting to an urban hospital via laboratories, microbiology, and antibiotic choice with respect to diabetic status. Materials and Methods Patients presenting with any hand infection were reviewed and stratified by DM status and infection location. Labs, culture results, antibiotic regimens, and significant predictors of laboratories or infection location were analyzed. Results Fifty-three patients were included: DM ( n = 24), no-DM ( n = 24), and unknown status ( n = 5). Culture rates were comparable between all groups. Mean erythrocyte sedimentation rate (ESR) was significantly higher in DM (76.19 vs. 51.33); mean white blood cell count (WBC) and C-reactive protein (CRP) were comparable. Diabetics had higher odds of increased ESR (odds ratio [OR] = 1.03). Diabetics received vancomycin/piperacillin/tazobactam (VAN/PTZ) significantly more often (52% vs. 8%). Providers treated DM with VAN/PTZ or any VAN-containing regimen more often than with any other regimen. Proximal infections had significantly higher mean CRP (136.9 vs. 50.5) and WBC (5.19 vs. 3.9) and higher CRP (OR = 1.02). Conclusion This study highlights the need for systematic criteria to better risk- stratify patients for appropriate antibiotic treatment. It may not be appropriate to treat both groups differently, as overly aggressive antibiotic selection may contribute to drug-resistance development.

Improved breastfeeding duration with Baby Friendly Hospital Initiative implementation in a diverse and underserved population

BACKGROUND

Few studies have evaluated the impact of Baby Friendly Hospital Initiative (BFHI) implementation on underserved populations in the United States. We undertook this study in New Mexico, a large southwestern state with a diverse population and limited health care access.

METHODS

A quasi-experimental, retrospective cohort design was used to compare short-term breastfeeding duration between a pre-BFHI and a post-BFHI cohort. Among the post-BFHI cohort, logistic regression models were fitted to predict short-term breastfeeding duration from both individual and cumulative exposure to inpatient maternity care practices (Steps 4 to 9).

RESULTS

Implementation of the BFHI and cumulative exposure to the Ten Steps increased short-term duration of any breastfeeding and exclusive breastfeeding at 2-6 weeks postpartum. Exposure to all six of the inpatient Ten Steps increased the odds of any breastfeeding by 34 times and exclusive breastfeeding by 24 times. Exposure to Step 9 ("Give no pacifiers or artificial nipples") uniquely increased the likelihood of any breastfeeding at 2-6 weeks postpartum by 5.7 times, whereas Step 6 ("Give infants no food or drink other than breastmilk") increased the rate of exclusive breastfeeding by 4.4 times at 2-6 weeks postpartum.

CONCLUSION

These findings demonstrate that the Baby Friendly Hospital Initiative can have a positive impact on breastfeeding among underserved populations.

Relationships within MOMS Orange County care coordinated home visitation perinatal program

PURPOSE

The study aimed to examine how registered nurses (RNs) and paraprofessional home visitors (PHVs) work together as a team to care for underserved perinatal women in a coordinated home visitation program.

DESIGN AND METHODS

Qualitative methods were used to understand the perspectives of three RNs and twenty PHVs who worked at MOMS Orange County, a community-based perinatal health program. Individual one-on-one interviews were administered with the RNs and focus groups with the PHVs. Qualitative content analysis was conducted to synthesize themes.

RESULTS

RNs perceived themselves as educators, mentors, and supervisors. PHVs thought of themselves as supporters, coaches, and advocates. Interdependence and proactive communication were favorable characteristics of the relationship in which RNs trained PHVs to provide health education. The positive interactions between RNs and PHVs appeared to enhance the client-healthcare provider connection.

CONCLUSIONS

Our study is one of the first to describe relationships and communication patterns among the healthcare team in a coordinated home visitation program in the United States. Future studies should examine how additional members of the team, including clients and healthcare providers, view their experiences with a home visitation program.

Cardiovascular Health, Adiposity, and Food Insecurity in an Underserved Population

This study investigated associations between cardiovascular health (CVH), adiposity, and food insecurity by race, sex, and health literacy in a sample of 800 underserved patients with obesity (body mass index [BMI] ≥ 30 kg/m²). CVH was assessed using American Heart Association Life’s Simple 7 (LS7) and adiposity was estimated using BMI and waist circumference (WC). Mixed models including interaction terms between food insecurity and sex, race, and health literacy were analyzed for LS7, BMI, and WC. Stratified models were analyzed as indicated by significant interactions. Mean BMI and WC were 37.3 kg/m² (4.6 SD) and 113.5 cm (12.4 SD), respectively. Among patients, 31% were food insecure and 31% had low health literacy. There were significant positive associations between food insecurity and BMI (p = 0.03) and WC (p = 0.03) in the overall sample. In sex-stratified models, women who were food insecure had higher BMI (p = 0.02) and WC (p = 0.007) than their food secure counterparts. Further, food insecure patients with better health literacy had greater BMI (p = 0.004) and WC (p = 0.007) than their food secure counterparts. Results suggest that adiposity is a greater burden in food insecure patients, which may be an important consideration for obesity treatment in underserved populations.

Emergent Neurosurgical Management of a Rapidly Deteriorating Patient with Acute Intracranial Hemorrhage and Alcohol-Related Thrombocytopenia

Alcohol intoxication is a common risk factor of traumatic brain injury (TBI) and carries a significant health-care burden on underserved patients. Patients with chronic alcohol use may suffer a spectrum of bleeding diatheses from hepatic dysfunction not well studied in the context of TBI. A feared sequela of TBI is the development of coagulopathy resulting in worsened intracranial bleeding. We report the clinical course of an intoxicated patient found down with blunt head trauma and concurrent alcoholic cirrhosis who was awake and responsive in the field. Hospital course was characterized by a rapidly deteriorating neurological examination with progressive subdural and subarachnoid hemorrhage and precipitating neurosurgical decompression and critical care management. Our experience dictates the need for timely consideration of the possibility of rapid deterioration from coagulopathic intracranial bleeding in the initial assessment of intoxicated patients with head trauma of unknown severity, for which a high index of suspicion for extra-axial hemorrhage should be maintained, along with the immediate availability of operating room and the necessary medical personnel.

mHealth Technology Use and Implications in Historically Underserved and Minority Populations in the United States: Systematic Literature Review

Background

The proportion of people in the United States who are members of at least two ethnic groups is projected to increase to 10% by the year 2050. This makes addressing health disparities and health inequities in minority populations increasingly more difficult. Minority populations, including those who classify themselves as African American and Hispanic, are using mobile phones to access health information via the internet more frequently than those who classify themselves as white, providing unique opportunities for those in public health and health education to reach these traditionally underserved populations using mobile health (mHealth) interventions.

Objective

The objective of this review was to assess studies conducted in the United States that have used mHealth tools and strategies to develop and implement interventions in underserved populations. This review also examines the ways in which mHealth strategies are being employed in public health interventions to these priority population groups, as mobile phone capabilities include text messaging, mobile apps, internet access, emails, video streaming, social media, instant messaging, and more.

Methods

A systematic literature review was conducted using key search phrases, the matrix method, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart diagram to identify key studies conducted between the years of 2009-2016 in the United States. These studies were reviewed for their use of mHealth interventions in historically underserved and minority populations.

Results

A total of 16,270 articles were initially identified using key search phrases in three databases. Titles were reviewed and articles not meeting criteria were excluded, leaving 156 articles for further review. After additional review for relevance and inclusion criteria, 16 articles were qualified and analyzed.

Conclusions

mHealth is a promising area of development for public health and health education. While successful research has been done using text messaging (short message service, SMS) and other mHealth strategies, there is a need for more research using mobile phones and tablet applications. This literature review demonstrates mHealth technology has the ability to increase prevention and health education in health disparate communities and concludes that more specified research is needed.

Evaluation of a Healthy Chinese Take-Out Sodium-Reduction Initiative in Philadelphia Low-Income Communities and Neighborhoods

OBJECTIVES

Sodium reduction in restaurant foods is important because 77% of sodium in the United States is consumed by eating prepared and restaurant foods. We evaluated a sodium-reduction intervention, Healthy Chinese Take-Out Initiative, among Chinese take-out restaurants in low-income neighborhoods in Philadelphia, Pennsylvania. Our objectives were to (1) analyze changes in the sodium content of food samples and (2) collect data on changes in chefs' and owners' knowledge about the health risks of sodium overconsumption, perceptions of the need for sodium reduction, self-efficacy for lowering sodium use, and perceptions of training needs for sodium-reduction strategies.

METHODS

The initiative trained chefs from 206 Chinese take-out restaurants on strategies to reduce sodium in prepared dishes. We analyzed changes in the sodium content of the 3 most frequently ordered dishes-shrimp and broccoli, chicken lo mein, and General Tso's chicken-from baseline (July-September 2012) to 36 months after baseline (July-September 2015) among 40 restaurants. We conducted a survey to examine the changes in chefs' and owners' knowledge, perceptions, and self-efficacy of sodium reduction. We used multilevel analysis and repeated-measures analysis of variance to examine effects of the intervention on various outcomes.

RESULTS

We found significant reductions in the sodium content of all 3 dishes 36 months after a low-sodium cooking training intervention (coefficients range, -1.06 to -1.69, P < .001 for all). Mean knowledge (range, 9.2-11.1), perceptions (range, 4.6-6.0), and self-efficacy (range, 4.2-5.9) ( P < .001 for all) of sodium reduction improved significantly from baseline (August 2012) to posttraining (also August 2012), but perceptions of the need for sodium reduction and self-efficacy for lowering sodium use returned to baseline levels 36 months later (August 2015).

CONCLUSIONS

The intervention was a useful population health approach that led to engaging restaurants in sodium-reduction practices. Local public health agencies and professionals could partner with independent restaurants to introduce environmental changes that can affect population health on a broad scale, particularly for vulnerable populations.

Healthy Parks Healthy People as an Upstream Stress Reduction Strategy

One of the primary goals of the Healthy Parks Healthy People (HPHP) program, located in the San Francisco Bay Area, is to offer group-based physical activities in natural settings. These activities arefor racially and ethnically diverse groups of individuals as an "upstream" strategy for improving health. This study investigated the health impact of selected two-hour HPHP Bay Area events that targeted low-income racial and ethnic minority groups using physiological and self-reported measures of stress and related variables. Study participants (N=52) in the selected HPHP Bay Area events donated saliva and filled out psychological measures of perceived stress (PSS-4; Cohen et al.) and mood state (I-PANAS-SF; Thompson, 2007) at the beginning and the end ofa two-hour guided walk in green spaces. Moreover, a measure of perceived restoration (SRRS; Han, 2007) was completed at the end ofthe walk. Study participants wore a physical activity self-monitoring device (Garmin Vivofit 2) to capture their step count and heart rate during the event. Stress, both measured by the analysis of salivary cortisol and self-reported perceived stress, significantly decreased over the course of the event (p<.0$) and there was a significant increase in positive mood (p<.05). The monitoring device also indicated that individuals were engaged in moderate levels of physical activity during the guided walks (<di>x</di> =8,990 steps, HR 95 bpm). The results encourage further development of nature-based health interventions to mitigate stress. Such interventions may be especially appropriate for low-income, urban, racial and ethnic minority groups that likely experience increased levels of stress due to social inequities and poor living conditions.

Brazilian Dental Students' Attitudes About Provision of Care for Patients Living in Poverty

The aims of this study were to investigate dental students' attitudes toward people living in poverty and the extent to which their perceptions were associated with their willingness to treat those patients in their future practice. All 910 dental students enrolled in three Brazilian public universities in 2010 were invited to take part in a cross-sectional survey. A total of 766 students (83.7% response rate) completed the self-administered questionnaire on their perceptions of and attitudes about poverty and their intention to provide dental care to poor people. The responding students showed slightly positive attitudes about people living in poverty; however, a high percentage (35%) reported thinking they were different from the rest of the population. Nevertheless, most of these students expressed willingness to provide care to underserved populations in their future practice; this willingness was found to be associated with their beliefs about poverty (OR 1.65; 95% CI=1.41-1.94). Overall, the study found that these dental students had altruistic views toward people living in poverty. However, they seemed to lack a deep understanding of poverty that may prevent them from acting on their good intentions.

Ethical issues in action-oriented research in Indonesia

BACKGROUND

Action-oriented research is one of the most frequent research types implemented to transform community health in Indonesia. Three researchers and 11 graduate students from a developed country in East Asia conducted a fieldwork program in a remote area in South Sulawesi Province. Although the project was completed, whether or not the international standards for human subject research were applied into that study remains unclear.

OBJECTIVES

This study aimed to examine ethical issues raised from that case, analyze constraints to the problems, and recommend alternatives to protect vulnerable populations from being exploited by local/international researchers.

METHODS

A problem-solving approach was used in this study. It began with problem identification, evaluation of the action-oriented research goal, investigation of the constraints to the problem, and recommendation of some relevant alternatives to address the central issue. Ethical Consideration: The approval for conducting the action-oriented research that being investigated in this work was only obtained from the Head of local district.

RESULTS

Some ethical issues were found in this case. No special protection for this population, no informed consent was obtained from the participants, exposure to social and economic risks, no future benefits for the subjects, and conflict of interests. Lack of control from the local research ethics committee and lack of competence of local researchers on human subject research were considered as the constraints to the problems.

DISCUSSION

Creating an independent research ethics committee, providing research ethics training to the local researchers, obtaining written/video consents from underserved populations, and meeting local health needs were recommended alternatives to solve these problems.

CONCLUSION

Indonesian government bodies should reform their international collaborative system on research involving human subjects. Exploitation may not occur if all participants as well as all local and national governing bodies understand the research ethics on human subjects and apply it into their practice.

Colorectal cancer screening at US community health centers: Examination of sociodemographic disparities and association with patient-provider communication

BACKGROUND

Colorectal cancer (CRC) screening rates are low among underserved populations. High-quality patient-physician communication potentially influences patients' willingness to undergo CRC screening. Community health centers (HCs) provide comprehensive primary health care to underserved populations. This study's objectives were to ascertain national CRC screening rates and to explore the relations between sociodemographic characteristics and patient-provider communication on the receipt of CRC screening among HC patients.

METHODS

Using 2014 Health Center Patient Survey data, bivariate and multivariate analyses examined the association of sociodemographic variables (sex, race/ethnicity, age, geography, preferred language, household income, insurance, and employment status) and patient-provider communication with the receipt of CRC screening.

RESULTS

Patients between the ages of 65 and 75 years (adjusted odds ratio [aOR], 2.49; 95% confidence interval [CI], 1.33-4.64) and patients not in the labor force (aOR, 2.32; 95% CI, 1.37-3.94) had higher odds of receiving CRC screening, whereas patients who were uninsured (aOR, 0.33; 95% CI, 0.18-0.61) and patients who were non-English-speaking (aOR, 0.42; 95% CI, 0.18-0.99) had lower odds. Patient-provider communication was not associated with the receipt of CRC screening.

CONCLUSIONS

The CRC screening rate for HC patients was 57.9%, whereas the rate was 65.1% according to the 2012 Behavioral Risk Factor Surveillance System and 58.2% according to the 2013 National Health Interview Survey. The high ratings of patient-provider communication, regardless of the screening status, suggest strides toward a patient-centered medical home practice transformation that will assist in a positive patient experience. Addressing the lack of insurance, making culturally and linguistically appropriate patient education materials available, and training clinicians and care teams in cultural competency are critical for increasing future CRC screening rates. Cancer 2017;123:4185-4192. © 2017 American Cancer Society.

Patient-reported outcome measures in a population of medically indigent patients with systemic lupus erythematosus in Puerto Rico

Objective:

To determine patient-reported outcomes measures in indigent patients with systemic lupus erythematosus receiving their healthcare through the Puerto Rico government managed care system and compare these measures with non-indigent patients treated in a private fee-for-service setting.

Methods:

A cross-sectional study was conducted in a cohort of 98 Puerto Ricans with systemic lupus erythematosus. Patients from the public group (n = 40) were treated in a university-based specialized systemic lupus erythematosus clinic and the private group (n = 58) in a community-based rheumatology practice. Demographic and clinical features and patient-reported outcomes measures per LupusPRO instrument were determined. LupusPRO captures quality-of-life measures in 12 domains. Differences among study groups were examined using chi-square, Fisher’s exact, t-tests, and the Wilcoxon signed-rank test.

Results:

The mean (standard deviation) age of the study population was 44.9 (12.0) years; 94 (95.9%) were women. Patients in the public setting were younger and were more likely to have renal disease and elevated anti-double-stranded DNA antibodies, and being treated with azathioprine and cyclophosphamide. Patients from the public sector were more likely to have better quality-of-life measures in the LupusPRO domains of pain/vitality and coping. No significant differences were observed for the domains of lupus symptoms, physical health, emotional health, body image, cognition, procreation, lupus medications, desires/goals, social support, and satisfaction with medical care.

Conclusion:

Despite having a lower socioeconomic status and worse clinical status, systemic lupus erythematosus patients from the public sector had equal or better patient-reported outcomes measures than those treated in the private setting. This favorable outcome may be associated with the comprehensive healthcare received by these patients in a specialized lupus clinic.

Colorectal Cancer Screening Navigation for the Underserved: Experience of an Urban Program

Colorectal cancer is the third leading cause of cancer deaths in the United States. Although colorectal cancer screenings are effective and recommended by all clinical practice guidelines, only 65.7% of adults ages 50 to 75 years are screened. Colorectal cancer screening is disproportionately underutilized in inner city populations. In 2011, the University of Pennsylvania Health System created a navigation program to specifically address poor colorectal cancer screening rates and increase access to colorectal cancer screening colonoscopies for patients in the underserved areas of West, South, and Southwest Philadelphia. We directed focus on issues surrounding barriers of screening so that we could best leverage our resources and impact the greatest number of patients. The program was designed to target patients who were either due for, never scheduled, or did not keep previously scheduled colorectal cancer screening colonoscopy appointments, or who were referred by providers concerned that the patients would not keep appointments or would misunderstand preprocedural guidelines. The program strives to improve colorectal health by providing free education and screening navigation through a navigator who assists patients from the first phone call to completion of the colonoscopy. This is accomplished by implementing an effective screening program while providing one-on-one service with a cost-effective navigator reaching out to patients who are nonadherent to colorectal cancer screening. Barriers included not having a companion to escort and transport the patient home from the procedure, poor awareness, fear of the procedure or sedation, limited funds to purchase preparation materials, inability to read or comprehend preparation instructions, and hardship in being contacted or scheduling appointments.

Measuring the Gap: A Health Assessment of Rural Chinese Children Compared to Urban Children

China is a large country where rapid development is accompanied by growing inequalities. How economic inequalities translate to health inequalities is unknown. Baseline health assessment is lacking among rural Chinese children. We aimed at assessing baseline student health of rural Chinese children and comparing them with those of urban children of similar ages. A cross-sectional study was conducted using the 2003 Global School-Based Student Health Survey among 100 students Grade 4 to 6 from rural Guizhou, China. Results were summarized and compared with public data from urban Beijing using multivariate logistic regression models. Rural children are more likely to not wash their hands before a meal (odds ratio [OR] = 5.71, P < .01) and after using the toilet (OR = 5.41, P < .01). They are more likely to feel sick or to get into trouble after drinking (OR = 7.28, P < .01). They are more likely to have used drugs (OR = 8.54, P < .01) and to have no close friends (OR = 8.23, P < .01). An alarming percentage of rural (8.22%) and urban (14.22%) children have had suicidal ideation in the past year (OR = 0.68, P > .05). Rural parents are more likely to not know their children's whereabouts (OR = 1.81, P < .05). Rural children are more than 4 times likely to have serious injuries (OR = 4.64, P < .01) and to be bullied (OR = 4.01, P < .01). In conclusion, school-age rural Chinese children exhibit more health risk behaviors and fewer protective factors at baseline compared to their urban counterparts. Any intervention aimed at improving child health should take this distributive gap into consideration.

Improving Access to Eye Care among Persons at High-Risk of Glaucoma in Philadelphia--Design and Methodology: The Philadelphia Glaucoma Detection and Treatment Project

PURPOSE

The Wills Eye Glaucoma Research Center initiated a 2-year demonstration project to develop and implement a community-based intervention to improve detection and management of glaucoma in Philadelphia.

METHODS

The glaucoma detection examination consisted of: ocular, medical, and family history; visual acuity testing; corneal pachymetry; biomicroscopy of the anterior segment; intraocular pressure (IOP) measurement; gonioscopy; funduscopy; automated visual field testing; and fundus-color photography. Treatment included laser surgery and/or IOP-lowering medication. A cost analysis was conducted to understand resource requirements. Outcome measures included; prevalence of glaucoma-related pathology and other eye diseases among high-risk populations; the impact of educational workshops on level of knowledge about glaucoma (assessed by pre- and post-test evaluation); and patient satisfaction of the glaucoma detection examinations in the community (assessed by satisfaction survey). Treatment outcome measures were change in IOP at 4-6 weeks and 4-6 months following selective laser trabeculoplasty treatment, deepening of the anterior chamber angle following laser-peripheral iridotomy treatment, and rate of adherence to recommended follow-up examinations. Cost outcomes included total program costs, cost per case of glaucoma detected, and cost per case of ocular disease detected.

RESULTS

This project enrolled 1649 participants (African Americans aged 50+ years, adults 60+ years and individuals with a family history of glaucoma). A total of 1074 individuals attended a glaucoma educational workshop and 1508 scheduled glaucoma detection examination appointments in the community setting.

CONCLUSIONS

The Philadelphia Glaucoma Detection and Treatment Project aimed to improve access and use of eye care and to provide a model for a targeted community-based glaucoma program.

HIV/HCV Co-infection: Overcoming Barriers to Treatment

A critical step in the eradication of hepatitis C virus (HCV) infection is access to effective therapy. With the advent of interferon-free regimens, HCV providers and patients gained hope that the success seen in clinical trials could be translated to the real world. However, the exorbitant cost of the new direct-acting antivirals limits access to these medications to the general HCV population, especially underserved patients with public insurance. We used a descriptive qualitative approach to detail the measures necessary and challenges faced by an inner-city nursing team in Washington, DC to obtain the new direct-acting antivirals. Significant time and dedication on the part of providers and staff was required to assist patients with the process of obtaining direct-acting antivirals.

A randomized, controlled trial to test the effectiveness of a glaucoma patient navigator to improve appointment adherence

PURPOSE

Patients with glaucoma who do not keep their follow-up eye care appointments are at risk for developing more severe ocular disease. The primary aim of the current study was to evaluate whether the use of a patient navigator altered adherence to follow-up eye care appointments in community-versus office-based settings.

PATIENTS AND METHODS

Patients diagnosed with a glaucoma-related condition following a comprehensive eye examination at 43 community sites in Philadelphia, PA, USA, were enrolled in this prospective, randomized, controlled trial. Patients were randomized into three groups for a 1-year period: Group 1 (G1) received follow-up eye care in a community-based setting with assistance from a patient navigator; Group 2 (G2) received follow-up eye care in an office-based setting with assistance from a patient navigator; and Group 3 (G3) received follow-up eye care in an office-based setting without a patient navigator (usual care). Adherence rates were compared among these three groups using a chi-squared test at a significance level of 0.05.

RESULTS

A total of 155 patients with glaucoma-related diagnoses were enrolled. The mean age (±standard deviation) was 71.2 (±10.0) years. Patients were predominantly female (65.8%, n=102/155) and African-American (71.6%, n=111/155). The mean (±standard deviation) number of follow-up visits during the 1-year study period was 1.3 (±1.3) for G1, 1.6 (±1.3) for G2, and 1.3 (±1.1) for G3 (P=0.48). Appointment adherence, defined as attendance of ≥1 follow-up visit, was 69.8% (n=37/53) for G1, 82.5% (n=47/57) for G2, and 73.3% (n=33/45) for G3, (P=0.28). Sub-analysis of adherence rates for patients who attended ≥2 follow-up visits were 91.3% (n=21/23) for G1, 74.3% (n=26/35) for G2, and 66.7% (n=18/27) for G3, (P=0.11).

CONCLUSION

Help from a patient navigator did not increase the likelihood of keeping ≥1 follow-up appointment in an office-based setting. Adherence rates for follow-up appointments reached close to 70% or above in a self-selected patient population.

Sauti Za Wananchi "voice of the people": patient satisfaction on the medical wards at a Kenyan Referral Hospital

Introduction

Patient satisfaction is one indicator of healthcare quality. Few studies have examined the inpatient experiences in resource-scarce environments in sub-Saharan Africa.

Methods

To examine patient satisfaction on the public medical wards at a Kenyan referral hospital, we performed a cross-sectional survey focused on patients’ satisfaction with medical information and their relationship with staffing and hospital routine. Ratings of communication with providers, efforts to protect privacy, information about costs, food, and hospital environment were also elicited.

Results

Overall, the average patient satisfaction rating was 64.7, nearly midway between “average” and “good” Higher rated satisfaction was associated with higher self-rated general health scores and self-rated health gains during the hospitalization (p = 0.023 and p = 0.001). Women who shared a hospital bed found privacy to be “below average” to “poor” Most men (72.7%) felt information about costs was insufficient. Patients rated food and environmental quality favorably while also frequently suggesting these areas could be improved.

Conclusion

Overall, patients expressed satisfaction with the care provided. These ratings may reflect modest patients’ expectations as well as acceptable circumstances and performance. Women expressed concern about privacy while men expressed a desire for more information on costs. Inconsistencies were noted between patient ratings and free response answers.

Primary care provider perceptions of the effectiveness of two self-management support programs for vulnerable patients with diabetes

BACKGROUND

Primary care providers (PCPs) in safety net settings face barriers to optimizing care for patients with diabetes. We conducted this study to assess PCPs' perspectives on the effectiveness of two language-concordant diabetes self-management support programs.

METHODS

One year postintervention, we surveyed PCPs whose patients with diabetes participated in a three-arm multiclinic randomized controlled trial comparing usual care (UC), weekly automated telephone self-management (ATSM) support with nurse care management, and monthly group medical visits (GMVs). We compared PCP perspectives on patient activation to create and achieve goals, quality of care, and barriers to care using regression models accounting for within-PCP clustering.

RESULTS

Of 113 eligible PCPs caring for 330 enrolled patients, 87 PCPs (77%) responded to surveys about 245 (74%) enrolled patients. Intervention patients were more likely to be perceived by PCPs as activated to create and achieve goals for chronic care when compared with UC patients (standardized effect size, ATSM vs UC, +0.41, p = 0.01; GMV vs UC, +0.31, p = 0.05). Primary care providers rated quality of care as higher for patients exposed to ATSM compared to UC (odds ratio 3.6, p < 0.01). Compared with GMV patients, ATSM patients were more likely to be perceived by PCPs as overcoming barriers related to limited English proficiency (82% ATSM vs 44% GMV, p = 0.01) and managing medications (80% ATSM vs 53% GMV, p = 0.01).

CONCLUSIONS

Primary care providers perceived that patients receiving ATSM support had overcome barriers, participated more actively, and received higher quality diabetes care. These views of clinician stakeholders lend additional evidence for the potential to upscale ATSM more broadly to support PCPs in their care of diverse, multilinguistic populations.

Impact of patient navigation from diagnosis to treatment in an urban safety net breast cancer population

Background: Disparities between U.S. population groups in cancer incidence, treatment and outcome have been well documented. Literature evidence is scarce regarding the impact of patient navigator programs on elimination of these differences.

Methods: This is a retrospective case series analysis .The pre -navigation group included patients diagnosed between January 1, 1997 and December 31, 1999. The post -navigation group included patients diagnosed between January 1, 2000 and December 31, 2003. Cancer stage, time from presentation to treatment and treatment outcome were compared by review of medical records.

Results: Three hundred and thirty five women were diagnosed between January 1, 1997 and December 31, 2003. Thirteen patients were ineligible, 103 women in the pre- navigation group, and 219 women in the post-navigation group. 157 (72%) received navigation services. The median time to first treatment was decreased by 9 days (42 days in pre -navigation group compared to 33 days in post -navigator group). Race, insurance and clinical presentation did not influence the time to treatment.

Conclusions: Navigation program did not influence the stage of presentation or the overall survival of women. There was a modest decrease in the time between initial presentation and definitive therapy. The utility of navigator programs is likely to vary with each institution.

Effectiveness of a psychoeducational parenting group on child, parent, and family behavior: a pilot study in a family practice clinic with an underserved population

Although integrated care for adults in primary care has steadily increased over the last several decades, there remains a paucity of research regarding integrated care for children in primary care. To report results of a pilot study testing initial feasibility of a parenting psychoeducational group targeting child behavioral problems within a primary care clinic. The participants (n = 35) were parents representing an underserved population from an inner-city primary care clinic. Participants attended a 12-week psychoeducational parenting group and reported pre- and post-measures of family functioning, child misbehavior and dyadic functioning. Paired t-tests and effects sizes are reported. Participants reported statistically significant improvement in family functioning, child misbehavior, and couple functioning after participating in the parenting psychoeducational group. Results suggest initial feasibility of a parenting psychoeducational group within a primary care clinic with an underserved population. This intervention may be useful for other primary care clinics seeking to offer more integrative care options for children and their families.

Interactive, culturally sensitive education on colorectal cancer screening

BACKGROUND

Increasing colorectal cancer screening (CRCS) can have a substantial positive impact on morbidity and mortality.

OBJECTIVES

The purpose of this report is to describe the development and feasibility testing of a computer-based, theory-guided educational program designed to increase CRCS.

RESEARCH DESIGN

This mixed-methods study used focus groups and subsequent randomized controlled trial design.

SUBJECTS

Participants (N = 199) were randomized to an intervention or control group; 75% were African American; mean age was 57.36 (SD = 6.8); 71% were male.

MEASURES

Previously validated measures on knowledge, beliefs, and screening test adherence were used to establish pre- and post-intervention perceptions. Feasibility was measured by response and completion rates, and participants' perceptions of the program.

RESULTS

Before feasibility testing, the program was presented to 2 focus groups. Changes were made to the program based on discussion, leading to a visually appealing, easy to understand and navigate, self-paced program. In the RCT pilot test that followed, of the participants in the intervention group, 80% said the education helped them decide to get CRCS; 49% agreed it helped them overcome barriers; 91% agreed it was useful, 68% thought it raised new concerns about cancer, but only 30% said it made them worry about CRC; 95% agreed their doctor's office should continue giving such education, and 99% said they would inform family about the program.

CONCLUSIONS

The response rate of 83% demonstrated feasibility of conducting colorectal cancer education in the primary care setting; overall the program was well received; participants averaged 23 minutes to complete it. Participants sought no help from attending data collectors and navigated the revised touch screen program with ease. Computer-based education is feasible in primary care clinics.