Showing papers in "Journal of Health Care for the Poor and Underserved in 2021"

Institutional Distrust among African Americans and Building Trustworthiness in the COVID-19 Response: Implications for Ethical Public Health Practice.

Abstract: African Americans are disproportionately affected by COVID-19-related disease and mortality due to long-standing social, political, economic, and environmental injustice; and COVID-19 inequities are exacerbated by institutional distrust. In the absence of trust, public health authorities have not adequately fulfilled their professional and ethical obligations to protect African American communities from the negative effects of COVID-19. As institutional distrust is shaped by individual and collective experiences of untrustworthiness, we propose a paradigm shift from increasing trust among African Americans to increasing trustworthiness among medical and public health institutions/systems throughout the United States. This narrative review extends the literature describing how social determinants contribute to COVID-19 inequities by demonstrating how institutional distrust develops over time and is reinforced through systems of injustice. Additionally, we illustrate consequences of institutional distrust for COVID-19 inequities and provide recommendations for building trustworthiness through ethical public health practice.

A Proposed Framework on Integrating Health Equity and Racial Justice into the Artificial Intelligence Development Lifecycle

Abstract: The COVID-19 pandemic has created multiple opportunities to deploy artificial intelligence (AI)-driven tools and applied interventions to understand, mitigate, and manage the pandemic and its consequences. The disproportionate impact of COVID-19 on racial/ethnic minority and socially disadvantaged populations underscores the need to anticipate and address social inequalities and health disparities in AI development and application. Before the pandemic, there was growing optimism about AI's role in addressing inequities and enhancing personalized care. Unfortunately, ethical and social issues that are encountered in scaling, developing, and applying advanced technologies in health care settings have intensified during the rapidly evolving public health crisis. Critical voices concerned with the disruptive potentials and risk for engineered inequities have called for reexamining ethical guidelines in the development and application of AI. This paper proposes a framework to incorporate ethical AI principles into the development process in ways that intentionally promote racial health equity and social justice. Without centering on equity, justice, and ethical AI, these tools may exacerbate structural inequities that can lead to disparate health outcomes.

Social Vulnerability Is Associated with Risk of COVID-19 Related Mortality in U.S. Counties with Confirmed Cases.

Abstract: OBJECTIVES: To determine the association between the Center for Disease Control and Prevention's (CDC) Social Vulnerability Index (SVI) with the risk of COVID-19-related mortality. METHODS: We merged by county CDC's SVI and the New York Times data on coronavirus cases. We estimated the association between the SVI and risk of death from COVID-19 per 100,000 people in counties with confirmed cases (n=2,755 U.S. counties) using multivariable Poisson regression. RESULTS: The adjusted risk of COVID-19-related death followed a non-linear pattern, with the lowest risk among SVIs from 0.05 to 0.55 (roughly 3.1 to 3.5/100,000 people) and highest risk corresponding to SVI=0.95 (6.5/100,000). Compared with a SVI=0.35, SVIs of 0.85 and 0.95 were associated with 2.3 (2.1, 2.5) and 3.4 (3.1, 3.7) excess deaths per 100,000, respectively. CONCLUSIONS: High social vulnerability is associated with increased risk of COVID-19-related mortality among U.S. counties with confirmed cases.

The Five A's of Access for TechQuity

Abstract: The COVID-19 pandemic caused a rapid and significant shift from in-person health care to care delivered virtually, highlighting the impact of disparities in access to technology. Penchansky and Thomas conceptualized the idea of access to health care as comprising five dimensions, known as the Five A's of access: affordability, availability, accessibility, accommodation, and acceptability. Considering these dimensions of access allowed health care systems to dissect barriers to access to better identify ways to overcome them. In the current health care landscape, we must consider technology access. For example, patients without Internet service, appropriate devices, and digital literacy skills experience greater challenges in accessing care via telehealth. To ensure equitable technology access, or techQuity, health care systems must identify data to monitor the Five A's of technology access. We re-envision the Five A's of access as they relate to access to technology for telehealth and present a framework for evaluating a health care system's techQuity.

What is TechQuity

Abstract: Three seminal reports, the 2001 Institute of Medicine's Crossing the Quality Chasm, the 2003 report Unequal Treatment,1 and the 2020 National Academy of Medicine's (formerly Institute of Medicine) Artificial Intelligence in Healthcare2 represented inflection points in highlighting the substantial disparities in access, clinical care, and outcomes, and recommended that equity in health care and health technology must be achieved to deliver quality care.3 Though Crossing the Quality Chasm set up the STEEEP framework, which explicitly called out equity as one of six health care quality domains (alongside safety, timeliness, effectiveness, efficiency, and patient-centered care) the issue of inequities in health care delivery was truly laid bare in Unequal Treatment, which also called upon health care institutions and providers to develop strategies to confront disparities in care.4 Artificial Intelligence in Healthcare introduced the "Quintiple Aim" where "Equity and Inclusion" was added to the "Quadruple Aim. Equity Dashboards The application of analytics to demonstrate health care quality in the domains of safety, timeliness, effectiveness, efficiency, and patient-centeredness has been common in diverse dashboards for hospital ratings and other key health care certifications (e.g., National Committee for Quality Assurance, Joint Commission);however, equity has often been overlooked.17 Peter Drucker, a famous business thinker and writer for the modern company, stated that "if you can't measure it, you can't improve it. [...]we must move AI from being a "black box" to a "clear box" with AI factsheets like nutrition labels where buyers and end-users of AI algorithms can transparently see who trained the AI, what datasets were used, and what specific AI algorithms and models were used.28 We must assure transparent, ethical, fair, and equitable AI. Institute of Medicine, Board on Health Sciences Policy, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care.

Organizational Strategies and Inclusive Language to Build Culturally Responsive Health Care Environments for Lesbian, Gay, Bisexual, Transgender, and Queer People.

Abstract: This report shares examples of organizational strategies and inclusive language that can be integrated into standard patient-facing processes, forms, and materials to create culturally responsive health care environments for lesbian, gay, bisexual, transgender, and queer people.

Understanding Black Women's Perspectives and Experiences of Cervical Cancer Screening: A Systematic Review and Qualitative Meta-synthesis.

Abstract: Cervical cancer is the third most common gynecological cancer. Effective population-based cervical cancer screening programs exist, but improvements in morbidity and mortality continue to demonstrate racial disparities. For example, Black women are 41% more likely to develop cervical cancer than White women and are 75% more likely to die from it. It is therefore important to understand whether these inequities in cervical cancer outcomes are related to differential access and uptake of screening programs. In this systematic review and qualitative meta-synthesis, we used an intersectional lens to understand Black women's experiences and perspectives of cervical cancer screening (CCS). We identified 12 factors related to the perspectives and experiences of Black women participating in CCS. Understanding Black women's experiences and perspectives of CCS can help individual clinicians and policymakers implement CCS in a way that is culturally appropriate and cognizant of structural oppression.

Mental Illness and Mental Health Care Treatment among People with Criminal Justice Involvement in the United States.

Abstract: This study analyzes the effect of arrest and community supervision on mental health and mental health care using a U.S.-based nationally representative data from National Survey of Drug Use and Health (NSDUH) and Behavioral Model for Vulnerable Populations. It conducts a bivariate analysis to estimate population prevalence rates and generalized structural equation modeling (GSEM) to test the conceptual model. Individuals who were recently arrested or under community supervision (probation/parole) are more likely to use treatment (medication, inpatient, and outpatient care) for mental health problems compared with those with no CJ contact. However, there still remains a large unmet need. Overall, people with mental illness may be accessing mental health treatment through their involvement with the CJ system more broadly. There is the need for multiple societal institutions to work in tandem and communicate with vulnerable individuals who experience CJ contact to further assess appropriate assistance and mental health treatment.

Experience with a Mobile Addiction Program among People Experiencing Homelessness.

Abstract: A mobile addiction-focused outreach program designed to improve access to care for people experiencing homelessness was implemented in response to the opioid overdose crisis. This innovative program was readily accepted among participants and can inform the development of similar programs delivering addiction-focused care to people experiencing homelessness elsewhere.

Content Analysis of Health Concerns among Housing First Residents with a History of Alcohol Use Disorder.

Abstract: Previous research has utilized survey and administrative data to document health problems among Housing First (HF) residents; however, little is known about residents' personal perspectives on their health. The purpose of this study was to utilize conventional content analysis to analyze health-related concerns among HF residents with histories of alcohol use disorder. Between June and December 2013, we interviewed 44 adults who had histories of chronic homelessness and alcohol use disorder and were residing in single-site HF in Seattle, Washington. Responses centered on five primary topics: alcohol-related harm, perceived health vulnerability, concern for fellow residents' health, end of life, and health and safety promotion. HF residents experience complex alcohol-exacerbated health difficulties and existing health services may not meet the needs of those whose health is particularly compromised. Considering that HF facilitates aging in place, end-of-life care and grief counseling should be integrated into HF services.

Implementation of an Isolation Shelter for Individuals with COVID 19 Experiencing Homelessness.

Abstract: The COVID-19 pandemic had a devastating impact on non-sheltered homeless and housing-insecure individuals. This report details the development of a Chicago-based isolation shelter designed for people experiencing homelessness and recovering from COVID-19. The model is informative concerning the rapid development of services for people marginalized by the health care system.

"She Showed Me How to Help Myself": A Qualitative Study of Health Coaching for Management of Chronic Obstructive Pulmonary Disease.

Abstract: Objective To explore attitudes and beliefs about the role of health coaching for vulnerable populations, including people experiencing substance use or homelessness. Methods From May-July 2016, we conducted semi-structured qualitative interviews with patients, primary care clinicians, pulmonary specialists, and health coaches participating in a study of health coaching for chronic obstructive pulmonary disease (COPD). We developed a codebook and applied it in Atlas.ti, generating themes for frequently occurring codes. Results All stakeholder groups (n=20 patients, 11 primary care clinicians, three specialists, and two health coaches), reported improved COPD management and behavior change, even for patients experiencing substance use or homelessness. Clinicians observed greater symptom awareness and prioritization of COPD during the medical visit. The strength of the health coaching relationship and flexibility of the role were key to its effectiveness. Conclusion Lay health coaching may provide a model to meet the needs of highly vulnerable populations with COPD.

Eviction as a Disruptive Factor in Health Care Utilization: Impact on Hospital Readmissions and No-show Rates.

Abstract: Background Residential eviction is a component of housing instability that negatively affects physical and mental health, but the effect of eviction on health care utilization, specifically hospital readmissions and outpatient no-show rates, is not known. Methods We conducted a retrospective review of health care utilization of individuals evicted from public housing between January 2013 and December 2017, investigating hospital readmissions and no-show rates one year before and after eviction. Results 131 individuals who had been evicted had one year of data pre-and post-eviction. The majority were African American (97.7%) and female (80.9%). There was no significant change in 30-, 60-, and 90-day hospital readmissions (p>.05). No-show rate decreased from 27.57 per person per year to 20.13 (p=.05). Conclusions For our study population, health care utilization was not disrupted. The decreased no-show rate represents an opportunity for health systems to engage with patients on social factors affecting their health post-eviction.

The Impact of Incarceration on Health and Health Care Utilization: a System Perspective.

Abstract: Background Previously incarcerated individuals report high rates of chronic disease and reduced health care access. We characterized the impact of recent incarceration in jail or prison on chronic disease burden and health care utilization. Methods and findings Incarceration data over 10 years were matched to health system data and patients were classified by recent incarceration status. Each cohort was stratified by gender and neighborhood socioeconomic status for utilization analysis. Main outcomes were chronic disease incidence and health care utilization. Incarceration had a significant but small effect on chronic disease incidence. Incarceration had a moderate to large effect on emergency department and behavioral health utilization, with additional differences seen by gender and socioeconomic status. Conclusion Incarceration's impact on quantity and type of health care utilization varies with socioeconomic status and gender. Future work should evaluate the impact of length or number of cycles of incarceration on health or health care utilization.

Mothers in a 'Strange Land': Migrant Women Farmers' Reproductive Health in the Brong-Ahafo Region of Ghana.

Abstract: As a coping strategy towards climate variability, smallholders from the Upper West Region (UWR) migrate to rural farming areas in the Brong-Ahafo Region (BAR) of Ghana in search of better livelihoods. Although previous migrations were seasonal and maledominated, recent migrations have become permanent and involve more women migrating. Despite these changing dynamics, little is known about the effects of internal migration on women's reproductive health in rural migration destinations. Using qualitative methods, we explored migrant women farmers' reproductive health experiences in BAR. Findings from our study reveal that migrant women face limited autonomy in family planning decisions, lack access to maternal and general health care services, and have limited social support in the migration destination. Our findings contribute to the migration literature and highlight the unique reproductive health challenges of agrarian migrant women in rural receiving societies of Ghana.

Comprehensive Medication Review Completion in Medically Underserved Areas and Populations

Abstract: Purpose Pharmacists provide comprehensive medication reviews (CMRs) to address provider shortages in medically underserved rural areas/populations (MUA/P). Currently, there are no studies regarding the proportions of CMRs completed directly with patients (here called, beneficiaries) from MUA/Ps themselves, or with others such as caregivers or primary care providers. Methods This retrospective study analyzed adults in 2018 who received a CMR from a telehealth pharmacist. Chi-square tests compared differences in the proportion of CMRs completed with beneficiaries versus others. Multivariable logistic regression determined predictors of CMRs completed with beneficiaries. Findings Of 19,655 participants, most were female (68%) and had Spanish preferred language (43%). The following had a greater likelihood of CMR completion with beneficiaries: age 65-74 years; non-rural residents; mental health prescription. These variables had less likelihood of CMR completion with beneficiaries: rural areas; men; and presence of medication nonadherence. Conclusion The expansion of pharmacist-delivered CMRs occurred successfully in MUA/Ps. Further work is warranted to investigate the longitudinal effect on health markers.

Targeting Hypertension: Working with Rural Barbershops to Identify Hypertension and Encourage Treatment.

Abstract: INTRODUCTION Cardiovascular disease (CVD), accounting for one in every four U.S. deaths, has had a devastating impact on Mississippi's African American population. Seeking innovative mitigation models, this study assesses CVD prevalence and reach via barbershops to rural Mississippi African Americans. METHODS Data was collected from barbershop clientele who consented to be screened and contacted for referral to clinical care if blood pressure was found to be elevated. RESULTS Most participants were African American (97.7%, n=2,756) and male (54.4%). Descriptive findings revealed more than one-third of participants (34.2%) had elevated blood pressure at screening. Factoring in those with hypertension in control, we found lower rates of hypertension in the male population (males 51.4% vs. females 57.8%), a sharp contrast to national rates. CONCLUSION Evaluation findings suggest CVD prevalence in rural Mississippi is comparatively high but that barbershop partners were able to successfully reach and screen the target population.

Engaging Community and Academic Partners to Explore Adolescent Emotional Well-Being.

Abstract: In an under-resourced area of the South Bay of Los Angeles, partnerships were formed between community advocates with extensive research experience, less experienced academic investigators, and an urban public high school without partnered research experience. This article outlines the process of developing these partnerships through a community-academic research conference addressing a priority area identified by the local community to define and understand the importance and relevance of adolescent emotional well-being. Teen participants from the high school identified support from the community as the most crucial ingredient for achieving adolescent emotional well-being.

Palliative Care Practices in a Rural Community: Cultural Context and the Role of Community Health Worker.

Abstract: In many communities in South Africa, no palliative care (PC) services exist. One strategy for increasing access to PC services is to integrate Community Health Workers (CHWS) into PC practice. The purpose of the study was to describe the palliative care practices of CHWS. A qualitative, explorative descriptive design guided the study. Thirty-four people participated in the study. Mean age of the participants was 53.7 years old, 98% were female, and 100% were affiliated with with non-governmental organizations. The mean numbers of years in practice was 10.2 and 36.5 for the CHWS and professional nurses respectively. After analysis of the data three major themes emerged: the influence of the Vha-venda cultural context, HBC palliative care practices, and the lack of palliative care resources & supplies. Despite a lack of resources, CHWS play an important role in PC by providing physical comfort, providing spiritual comfort, educating patient-family, and supporting medication management.

Impact Of Supply- and Demand-Side Interventions Integrated with Antenatal Care on Use of Maternal Health Services-Western Kenya, 2013‒2014.

Abstract: We evaluated whether antenatal supply-side and demand-side interventions in 10 public health care facilities (HCFs) increased the percentage of women who had four or more antenatal care (ANC4+) visits and HCF deliveries from baseline to follow-up compared with women in 10 public control HCFs in Kenya. We compared maternal registry data during baseline and follow-up periods between public intervention and public control HCFs; we added seven private intervention HCFs and five private control HCFs to evaluate an unanticipated pilot insurance program that enabled women to use private intervention HCFs. From baseline to follow-up, ANC4+ visits and HCF deliveries in public intervention HCFs were 1.64 and 1.19 times greater, respectively, than in public control HCFs. Health care facility deliveries were 1.5 times higher in private intervention HCFs than public intervention HCFs. Results suggested that the combined antenatal and insurance interventions motivated increased ANC4+ visits and HCF deliveries. Women appeared to prefer private HCFs for delivery.

Pilot Hearing Screening of School-age Children in Lagos, Nigeria.

Abstract: Objectives The aim of this pilot study is to assess the prevalence of hearing disorders in school-age children in Lagos, Nigeria. Methods The study group consisted of 236 children aged 5 to 11 years old. Children were assessed by otoscopy, transiently evoked otoacoustic emissions, and pure-tone audiometry screening. Results Abnormal audiograms were found in 46 (19.5%) of the tested children. Otoscopy data suggest that the most frequent hearing abnormalities were related to cerumen and otitis media. Low agreement (55%) was found between otoacoustic emissions outcomes and pure-tone audiometry data. Conclusion Given the high prevalence of hearing problems in this group of primary school students, there is a strong need to monitor the hearing status of children in this geographical area.

Counting the Unsung by Promoting Participation in the 2020 US Census: A Survey of Migrant Workers in Washington State.

Abstract: INTRODUCTION Participation in the United States Census is critical for determining congressional representation and federal funding, but in every census there are groups systematically undercounted due to socioeconomic and demographic factors. Migrants and refugees are a group particularly threatened by being undercounted, including Hispanic migrant workers living in more rural areas. METHODS AND RESULTS To gather information to promote migrant participation in the census, the Community Health Worker Coalition for Migrants and Refugees in Washington state conducted a systematic survey of 71 migrant workers in seven urban and suburban Washington communities. The results showed that while most participants had heard of the census, basic knowledge about the census was limited and people wanted more information. CONCLUSIONS AND RECOMMENDATIONS A strong, coordinated outreach approach should be carried out to educate people in migrant communities about the census. This may involve one-on-one structured conversations, radio telenovelas, and community conversations organized by the trusted leaders.

Sociodemographic Differences in Asthma Self-Management Knowledge of Parents Seeking Asthma Care for their Children in Pediatric Emergency Departments.

Abstract: To effectively support asthma self-management among children most at risk for poor outcomes, it is important to examine potential disparities in parents' asthma-related knowledge. This study draws on baseline data collected from a randomized controlled trial to analyze how knowledge of asthma self-management varies by sociodemographic characteristics in a racially and economically diverse sample of Medicaid-insured children seeking emergency asthma care (N=221). Multivariable linear regression revealed that parent race/ethnicity, preferred language, and education were independently associated with scores on the Asthma Self Management Knowledge Questionnaire, and there was a significant interaction between parent race/ethnicity and education. In analyses stratified by parent education level, Latinx race/ethnicity was associated with lower-self-management knowledge among parents with higher education level, but not among those with a lower level of education. Our findings call for further research to understand and address the unique barriers to improving asthma self-management knowledge among Latinx parents and parents with limited English proficiency.

Establishing the Early Psychosis Intervention Clinic, New Orleans (EPIC-NOLA): Sustainability Challenges Threaten Clinical Success.

Abstract: This paper describes the implementation of the first coordinated specialty care clinic for first episode psychosis in New Orleans, Louisiana (Early Psychosis Intervention Clinic-New Orleans), a historically underserved area. Successes, lessons, and challenges will be explored in the context of a mission to provide highest quality clinical care in the current insurance reimbursement systems.

Development of a Resource Guide to Help Patients Receive Appropriate Care.

Abstract: After 10 years researching physician wrongdoing (i.e., sexual violations, improper prescribing, and unnecessary procedures), we developed a resource guide to help patients receive appropriate care and respond to inappropriate care. We gathered evaluative patient feedback, engaged physicians, and disseminated the guide. It is available at beforeyourvisit.org.

Associations of HCV Knowledge and Medical Mistrust with Being Screened for HCV and Offered HCV Treatment among People with HIV.

Abstract: An estimated one-fourth of people with HIV in the U.S. are coinfected with hepatitis C virus (HCV). We examined patient-related correlates of HCV screening and treatment in a convenience sample of 1,853 HIV-positive adults in Connecticut, Louisiana, New York, North Carolina, Pennsylvania, and Texas. Overall, 85.1% reported being screened for HCV, and 30.8% reported ever being offered treatment. In multivariate logistic regressions, greater HCV knowledge, lower HCV-related medical mistrust, older age, and prior substance use treatment were associated with higher screening and treatment likelihoods. For screening, Ryan White HIV/AIDS Program eligibility, having a high school education or less, and identifying as "other" race/ethnicity were additionally significant. Mistrust, which has arisen as a response to centuries of systemic racism, mediated the association between combined Black/Latino race/ethnicity and lower screening likelihood. We recommend patient-level (e.g., peer navigation) and provider interventions to integrate HCV screening and treatment into HIV care.

Homeless Vulnerability During an Opioid Epidemic: Assessing the Mortality Risk Among People Experiencing Homelessness in Southern Californai

Abstract: People experiencing homelessness suffer from a risk of mortality three to four times that of the general population, with drug-induced overdose replacing HIV as the emerging epidemic. This study assessed markers of mortality among people experiencing homelessness (N=157) in Orange County, CA during the Fall of 2016. We utilized the Vulnerability Index, an eight-question survey, to identify factors that may affect mortality risk among individuals experiencing homelessness and included two additional questions to identify potential risk of drug-induced overdose. Eighty-three percent of participants reported more than one heightened mortality risk marker and 64% may be at higher risk of drug-induced overdose. Given the state of the opioid epidemic, there is pressing need to couple public health interventions targeting people experiencing homelessness with harm reduction efforts including naloxone distribution (opioid-induced overdose reversal medication) and syringe exchange programs.