Health Disparities

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    A Rapid Systematic Literature Review: Barriers to Health Services in Pediatric Refugee Populations
    (2024-03-21) Abbas, Hibah; Hudson, Megan; Spitzer, Lillian; Allsopp, Leslie
    Purpose: Pediatric refugee populations in the United States have lower rates of immunization, difficulty accessing health care, decreased access to health insurance, and lower preventative visit attendance. This systematic review seeks to analyze the existing literature on health services for refugee children in the United States and to understand the socio-demographic, cultural, and systemic factors that contribute to these challenges. Two research questions were investigated: 1) what barriers are identified in the literature to the provision of adequate healthcare among refugee children in the United States, 2) does evidence suggest there are existing services and solutions that are accessible to refugee communities? Methods: A systematic search of electronic databases, including PubMed, CINAHL, and SCOPUS, was conducted to identify relevant peer-reviewed articles published. PRISMA guidelines for rapid reviews were followed, keywords were defined, and Covidence was used to structure content. The initial search produced 547 studies, and after 34 duplicates were removed, 513 studies remained. Title and abstracts were screened based on inclusion criteria, specifically, studies published in the last 10 years that referenced health services for pediatric refugee populations. Studies were excluded based on incorrect participant age and population specifications. Editorials and non-peer-reviewed articles were also excluded. 79 articles received a full-text review, with 13 articles meeting all inclusion criteria. These articles (n=13) were analyzed, content related to the research questions was classified using a data extraction tool, and common themes and patterns were identified. Results: Nine common themes isolated among the articles were linguistic differences, trauma-related mental health issues, lack of insurance coverage, cultural differences, limited health literacy, transportation difficulties, stigma, social isolation, and insufficient housing. The most prevalent theme isolated was linguistic differences with 11 out of the 13 studies that met inclusion criteria including it as a barrier to accessing healthcare. While these are listed as distinct themes and patterns, it is important to note that many of these barriers are interrelated. Our review revealed a lack of coherent and consistent services designed to meet the complex needs of this high-risk population. Conclusion: This rapid systematic review highlights the need for targeted interventions and policies that address the complex and interrelated barriers refugee populations face in accessing health care services. There does not appear to be consistent services that target this population specifically. In prior studies, refugee children were shown to have lower rate of immunizations, emphasizing the need for improved vaccination outreach strategies and health education. The isolated nine barriers serve as a foundational starting point to build targeted interventions to better serve this vulnerable population. Since linguistic differences were the most prevalent barrier to care, targeted interventions should include translators, either in-person or virtual, to be made available at clinics to provide care to this population. Ultimately, a more comprehensive understanding of these barriers through further research and policy development can improve health equity and outcomes for pediatric refugee populations in the United States.
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    The ethical implications of gender bias in clinical research: a Narrative Review
    (2024-03-21) Quinn, Quincey; Tucker, Zachary; Yockey, Andrew; Fulda, Kimberly
    Introduction: Sex bias in clinical research emerged in the 1960s after the 'thalidomide babies' incident, causing ethical concerns and a culture of abundance of caution. This led to the systematic exclusion of females, contributing to the exclusion of women as a gender identity. While sex bias has been extensively explored, gender bias merits separate consideration as gender bias affects the healthcare of an expanded group of individuals. Purpose: The purpose of this study was to conduct a narrative review on the ethical implications of gender bias in research with the following questions in mind: What are the implications of sex and gender bias in clinical research? What is the current landscape of gender bias in clinical research? Where can we improve consideration of sex and gender in clinical research to increase healthcare outcomes for women and those assigned female at birth? What are the participation differences in research by gender? What are barriers (social, economic, practical) to research by gender? Are there ethical implications to the inclusion/exclusion criteria for research participants by gender identity? Methods: A narrative review utilizing 8 databases (PUBMED, Scopus, CINAHL Complete, EBSCO host, APA Psych Info, Families Studies Abstract, MEDLINE Complete) from 2013 to August 2023 was performed. Search terms: “women OR woman OR female,” “research OR clinical research,” “sex bias or gender bias” and “underrepresent OR ethic OR equity.” 90 articles were reviewed by 3 researchers and evaluated for inclusion. A total of 45 articles were utilized for the final review. Results: In the analysis of five key questions, gender-related discussions were limited. The ethical implications of sex and gender bias in clinical research were acknowledged, emphasizing the need for ethical considerations related to sex bias, including varied safe doses, potential risks to pregnant individuals, and the impact on patient outcomes. The current landscape of gender bias in clinical research remained largely unaddressed, but insights into sex bias were provided, highlighting recent guidelines, disparities in representation, and the pervasive issue of sex bias across different specialties. Participation differences and barriers in research by gender were explored, with a focus on social, economic, and practical aspects. Barriers included education, economic stability, practical challenges, and researcher-imposed biases, affecting recruitment and retention. In addressing the ethical implications of inclusion/exclusion criteria based on gender identity, the study touched on the utility of studying transgender individuals due to hormone profiles, with one author recognizing the importance of the question. Conclusion: There is a need for education of the scientific community on the difference between gender and sex. The dataset gathered yielded limited information due to the inconsistent use of gendered and sex terms. More women need to be included in research both as participants and as authors to address gaps in professional development in academia and address the underpinnings of bias in the workforce. Further strategies to work towards equity include enforcing pre-existing guidelines, utilizing the participation-to-prevalence ratio, combating misinformation, and modifying inclusion criteria for greater inclusivity.
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    Perceived Vulnerability When Drinking: Daily-Level Associations with Alcohol Use and Consequences by Sexual Minority Status Among Adolescent Girls and Young Adult Women
    (2024-03-21) Vrotsos, Katherine; Graupensperger, Scott; Litt, Dana; Lewis, Melissa
    Purpose: Although cross-sectional research on perceived vulnerability (i.e., the likelihood of experiencing consequences if the individual were to engage in a behavior) when drinking suggests that greater perceived vulnerability is associated with less alcohol use and fewer alcohol-related consequences between-persons, there has been minimal research and mixed findings on within-person perceived vulnerability to alcohol-related consequences at the daily-level. Women have been found to experience more alcohol-related consequences compared to men, which may relate to their levels of perceived vulnerability. Additionally, sexual minority girls and women appear to be at increased risk for engaging in greater alcohol use and experiencing more alcohol-related consequences compared to heterosexual women, which may exacerbate their perceived vulnerability. The present study aims to (1) examine daily-level associations between perceived vulnerability and alcohol use and consequences among adolescent girls and young adult women and (2) assess whether sexual minority status moderates the association between perceived vulnerability and alcohol use and consequences at the daily-level. Methods: Participants were recruited as part of a longitudinal ecological momentary assessment (EMA) study conducted in Texas. Participants completed up to two surveys each day (eight surveys per week) in 3-week EMA bursts, which were repeated quarterly across the 12-month study. The sample for the current study included 410 cisgender (i.e., gender identity aligns with sex assigned at birth) adolescent girls and young adult women ages 15 to 25 (M= 20.8) who reported drinking days (44.9% White, Non-Hispanic; 39.8% sexual minority). The analytic sample included 3526 drinking days. Planned Analyses: In each multilevel model, daily-level predictors will be centered-within-person and person-level predictors will be grand-mean-centered. Age, race/ethnicity, weekend/weekday, week in burst, and burst number will be used as covariates in all models. Perceived vulnerability will be used as the predictor for (H1a) alcohol use (i.e., number of drinks) estimated with a mixed effects zero-truncated negative binomial model (count outcome starting at 1) and (H1b) the number of alcohol-related consequences estimated with a mixed-effects zero-inflated negative binomial model (count outcome with excessive zeros). Sexual minority status will be used as a moderator within these models (H2). Hypothesized Results: On drinking days when individuals report greater perceived vulnerability than their average, it is predicted that they will engage in less alcohol use (H1a) and experience fewer negative consequences (H1b). The daily-level associations between perceived vulnerability and alcohol use (H2a) and consequences (H2b) are predicted to be stronger among sexual minority individuals compared to heterosexual individuals. Potential Conclusion: The findings of this study have the potential to increase our understanding of how perceived vulnerability at the daily-level influences drinking among adolescent girls and young adult women, as well as differences based on sexual minority status. These findings could potentially improve the precision and efficacy of in-the-moment preventative interventions by identifying when girls and women are at increased risk of experiencing alcohol-related harm. Furthermore, these findings may inform the need to tailor in-the-moment interventions to target sexual minority girls and women.
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    Addressing Disparities in Treatment for Substance Use Disorder Among Individuals with Developmental Disabilities: Perspectives from Treatment Facility Employees
    (2024-03-21) Yip, Maggie; Phan, Cong-Bao; Espinoza, Anna; Walters, Scott; Barnett, Tracey; Bednar, Hannah; Garcia, Lizbeth; Taha, Suha; Miller, Jackson; Lopez, Cindy; Fulda, Kimberly
    Purpose Research on substance use disorder (SUD) among individuals with developmental disabilities (DD) is limited. The extant literature suggests that people with DD are less likely to use substances overall compared to people without a disability; however, they are more susceptible to SUD if they do use substances. Among facilities in the United States that provide aid for individuals with DD and treatment facilities for individuals with SUD, there are currently no interdisciplinary practice guidelines or training materials available for providers treating those with a co-diagnosis of DD and SUD. Our project aims to reduce the disparities between treatment guidelines and materials available for people with a co-diagnosis of both SUD and DD. The purpose of this analysis was to gauge overall awareness of providing treatment for individuals with SUD/DD co-diagnosis and reflect on current protocols regarding this population. Methods In this project, interviews were conducted with workers at facilities that primarily provide SUD services. Relevant facilities were identified and selected through systematic internet searches. In this study, 11 questions were asked to workers at facilities through 15-30 minute phone interviews. Questions that were used for this analysis revolved around themes of workers’ perspectives on the importance of integrating SUD/DD services, their current practices, and their future recommendations for integrating care for individuals with both SUD/DD. Results We conducted a total of 12 interviews. Responses came from the South and Midwest United States geographical regions. From these interviews, we found that most programs aim to individualize their approaches to treating this specific population. However, there is no standardized approach to how they individualize these cases. Furthermore, many programs expressed that they rarely refer individuals with a co-diagnosis of SUD/DD outside of their agency and feel inadequately prepared to treat individuals with SUD/DD co-diagnosis, which further emphasizes the need for accessible standardized guidelines. Overall, many workers expressed a need for improved access to screenings, assessment tools, specific guidelines, knowledge, training, and specialized programs for the variety of specific types of DDs. Conclusions People with DD that experience SUD are a vulnerable population with few resources. To meet the needs of this vulnerable population, standardized guidelines and training materials should be developed to address the specific needs of this patient population and equip healthcare providers and stakeholders with the tools necessary to ensure this population has proper and equitable access to treatment.
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    Discussion on Treating Pyelonephritis and Borderline Sepsis on Medical Mission Trips
    (2024-03-21) Thompson, Jordan; Garcia, Bianca; Hadley, Lesca
    Discussion on Treating Pyelonephritis and Borderline Sepsis on Medical Mission Trips Bianca Garcia OMS-II, Jordan Thompson OMS-III, Lesca Hadley, MD The Texas College of Osteopathic Medicine, UNT Health Science Center, Fort Worth, TX; Antigua, Guatemala Medical Mission Introduction: The case report discusses the diagnosis and management of pyelonephritis while on a DOCARE medical mission trip in Guatemala. Pyelonephritis is a common and very treatable diagnosis in the United States due to easy access to resources and physicians. This case is unique because it discusses the specific challenges providers faced not only managing but diagnosing the disease due to limited resources and lack of follow up care. The goal of this case report is to demonstrate the unique obstacles providers faced while working on a medical mission trip. Case Summary The patient was a 27 yo female who presented to the clinic with nonspecific complaints of pelvic pain and 3 days of dysuria, polyuria and thick/yellow discharge. Upon arrival at the clinic, the patient had a BP of 115/70, pulse 91 and a temperature of 100.7. Urinalysis demonstrated moderate leukocytes and negative pregnancy test. Physical exam demonstrated negative CVA tenderness. The differential for the patient remained UTI vs pyelonephritis. The patient’s temperature and pulse met 2/4 SIRS criteria which was concerning for a more serious infection such as pyelonephritis. However, the lack of CVA pointed more towards UTI. Making a treatment planned posed challenges because without a leukocyte count or blood cultures there was no way to confirm pyelonephritis. Providers knew that it was unlikely for the patient to receive follow-up care if the infection were to progress. Due to this, it was elected to choose a more aggressive treatment for pyelonephritis with 500mg ciprofloxacin BID for 14 days and instructions to find a hospital if symptoms worsen. Conclusions In the village of the DOCARE clinic, only 10% of the village has access to health care. The closest public clinic is 1.5 hours away and hospital is 2 hours away. Based on literature review, the standard of care for pyelonephritis would include of larger workup with blood cultures to guide antibiotic choice and close monitoring and follow-up of the patient. This standard of care was not available in Guatemala. Understanding of the resources available to the patient was a key factor in choosing a more aggressive treatment for the patient.
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    Identifying Stigmatizing Language in Maternal Mortality Medical Health Records
    (2024-03-21) Gi, Ashley; Raines-Milenkov, Amy
    Issue: This presentation endeavors to comprehensively address the ever-growing issue of stigmatizing language within medical health records, particularly in regards to maternal mortality. Maternal mortality remains a pressing health concern, with stark disparities persisting among different demographic groups. There is a notable gap in the identification of bias and disparities within medical records, with stigmatizing language being one manifestation of this bias. Stigmatizing language in medical records perpetuates harmful stereotypes, undermines patient trust, exacerbates disparities, and hinders equitable care delivery. This review focuses on the Maternal Mortality Case Preparation process which involves a systematic review of maternal death cases to identify contributing factors in hopes of reducing maternal mortality rates. Setting: The objective is to equip maternal mortality abstractors with the necessary resources to identify and abstract stigmatizing language present in maternal death medical records, fostering a more accurate and unbiased documentation process. Project: Efforts were directed towards refining a specialized tool to primarily assist Maternal Mortality Case abstractors and MMMRC Reviewers in identifying bias and stigmatizing language within medical records. The tool helps abstractors and Reviewers identify instances of discrimination within medical records that may have contributed to maternal death, ensuring a comprehensive approach to mitigating biases and promoting equitable maternal healthcare. Additionally, an accompanying PowerPoint presentation was developed to raise awareness about the harmful impact of stigmatizing language and provide guidance on alternative language usage to promote inclusivity and sensitivity in medical documentation. Results: Through a comprehensive literature review, common forms of stigmatizing language prevalent in medical health records have been identified. These include the use of quotations, which may inadvertently portray certain patient attributes or conditions in a derogatory manner. Moreover, language that utilizes doubt markers and judgemental language indicates a lack of trust or skepticism towards the patient's reported experiences or medical history. Lastly, blaming patients by using disapproving language not only perpetuates negative stereotypes but also undermines patient autonomy and dignity. By recognizing and categorizing these common forms of stigmatizing language, healthcare professionals can become more aware of their inadvertent biases and strive towards promoting more respectful and patient-centered communication within medical documentation. Conclusion: The development and refinement of this tool and educational resource represent significant progress in addressing stigmatizing language within medical health records. By raising awareness on the harmful implications of stigmatizing language, we can work towards improving the quality of care provided and reducing disparities in maternal health outcomes. Furthermore, the lessons learned from this initiative emphasize the broader significance for promoting equity and inclusivity within healthcare systems, underscoring the importance of addressing bias and discrimination in medical documentation across all healthcare specialties. Through continued research, education, and advocacy efforts, we can strive towards a healthcare system that is truly inclusive, equitable, and respectful of all patients' diverse backgrounds and experiences.
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    Using the Socioecological Model to Explain Disparities in Pain Management Between Hispanic and White Adults: A Literature Review
    (2024-03-21) Sarathy, Swathi
    Purpose: There is a longstanding history of racial disparities in pain management in the United States. Previous research has highlighted a trend in which Black and Hispanic patients are disproportionately at risk of experiencing inadequate pain treatment. For instance, studies have established that they are less likely to be prescribed analgesia and opioids compared to their White counterparts. Despite this knowledge, the underlying factors contributing to these disparities remain largely unexplored, particularly those concerning the Hispanic adult population. The purpose of this literature review is to utilize the socioecological model to explore patient, provider, and societal factors contributing to disparities in pain management between White and Hispanic adults. Methods: The literature review was conducted on PubMed. A combination of key terms was used to search for articles discussing disparities in pain management between Hispanic and White adults. Articles were included in the review if they were written in English, based in the United States, published in 2013 or later, and utilized one or many keywords in the title or abstract. Furthermore, only quantitative and qualitative studies, systematic reviews, and narrative reviews were considered. Using these criteria, a total of 18 articles were selected for review. Results: The results of this literature review support the notion that socio-ecological factors interact with one another and collectively contribute to disparities in pain management. At the patient level, differences in coping styles, underreporting pain, and perceived racial discrimination influence Hispanic patients' decision to seek pain management care from healthcare providers. At the provider level, bias and discrimination against Hispanic patients regarding pain treatment, along with language barriers, contribute to unequal healthcare practices. Finally, at the societal level, social and economic barriers impact Hispanic patients' ability to access and afford pain management care. Conclusion: This literature review aimed to identify patient, provider, and societal level factors that contribute to disparities in pain care between Hispanic and White adults in the US. Understanding the unique challenges the Hispanic adult population face is crucial for developing targeted interventions and improving equitable access to pain management services. Therefore, healthcare providers should strive to identify and mitigate as many of these factors as possible to alleviate disparities in pain management and deliver equitable care.
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    Assessing Barriers to Clinical Trial Enrollment Among African American Cancer Survivors in Louisville
    (2024-03-21) Ansarizadeh, Yosef
    Purpose: Despite comprising approximately 22% of the population of Louisville, KY, African Americans comprise about 9% of cancer clinical trial (CCT) participants. Nationally, minority participation in clinical trials is also low, with African Americans making up between 4-6% of CCT participants, despite constituting 15% of all US cancer patients. The goal of this study is to examine factors contributing to low African American participation in cancer clinical trials, specifically within the Louisville area. Previous research attributes low CCT participation to generational mistrust stemming from historical abuses of Blacks in clinical research. Research has demonstrated that low cancer literacy, lack of familiarity with clinical trials, and implicit bias can contribute to low minority recruitment to clinical trials. In order to make CCTs more representative of the general population, increasing generalizability of results, barriers must be understood before successful interventions can be trialed. Methods: By conducting focus groups and individual interviews with African American cancer survivors (AACS) (n=33), we sought to understand the barriers to CCT participation in the Louisville area. Results: The qualitative study revealed that a majority of AACS had not received information about CCTs from their healthcare teams, but a majority expressed interest in receiving information about CCTs. Conclusion: This data, though potentially confounded by the composition of the cohorts analyzed, suggests a need for community outreach and education specifically centered around CCTs. Keywords:[Cancer clinical trials, representation, barriers, cancer survivors]
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    Association of Pediatric Head Trauma with Attention Deficit Hyperactivity Disorder (ADHD) among School-aged Children in the United States
    (2024-03-21) Eberwein, Andrew; Pinnamraju, Jahnavi; Sambamoorthi, Usha
    Background Pediatric concussion is an important issue in healthcare that has gained recognition in recent years. Concussion may lead to negative emotional and cognitive consequences. ADHD may be a potential neurobehavioral consequence of head trauma, with evidence suggesting an increased likelihood of ADHD in individuals who have experienced concussions or have a history of head trauma. Objective This study examined disparities in pediatric head trauma and the association of a history of pediatric head trauma with ADHD using nationally representative data from the United States. Methods We performed a cross-sectional study using the 2021 National Health Interview Survey (NHIS). The study was restricted to school-aged children (5-17 years) with no missing information on ADHD or head trauma. There were 5,960 participants representing ~52.11 million US children. Our key independent variable was concussion (Yes/No) with yes indicating a positive response to any question in the 2021 NHIS survey fitting the following descriptions: “ever lost consciousness”, “ever told had a concussion”, “ever dazed or memory gap”, and “ever headache, vomit, blurred vision, or mood change after blow to the head.” ADHD was derived from a question that asked about the diagnosis of ADHD by a health professional or doctor. We performed Rao-Scott Chi-square tests and logistic regression analyses to identify the association of concussion with ADHD while controlling for other explanatory variables (sex, race & ethnicity, age, poverty status, food security, housing security, problem paying medical bills, health insurance, region, metro, family structure, adult education level). All analyses were conducted with SAS 9.4 survey procedures. Results Among the sample, 8.1% had experienced head trauma, and 10.6% had been diagnosed with ADHD. A lower percentage of Non-Hispanic Blacks (NHB) experienced head trauma (5.5% vs. 9.6%) compared to Non-Hispanic Whites (NHW). A higher percentage of males (9.1% vs. 7.0%) had head trauma compared to females. The prevalence of head trauma was higher in minors 14-17 years (13.3% vs. 4.9%) compared to 5–10-year-old children. A higher percentage of those with head trauma (20.7% vs 9.8%) had ADHD compared to those without head trauma. After adjustment for other covariates, children with concussion were more likely to report ADHD (aOR = 1.81, 95% CI = 1.34, 2.45) compared to those without concussion. Conclusion NHWs, males, and minors aged between 14-17 years were more likely to report a history of head trauma. Head trauma was associated with ADHD even when adjusted for confounding variables. It has been speculated in the past that NHW predominance in head trauma may represent greater prevalence of reporting rather than an actual increase in head trauma in this group raising the question of whether lack of injury recognition in minority demographics represents a possible area of improvement for improved health outcomes. In addition, the positive correlation between ADHD and pediatric head trauma warrants further investigation to establish possible causal relationships.
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    Do sociodemographic, health behaviors, and clinical factors predict levels of hs-CRP stratified by race and ethnicity?
    (2024-03-21) Modisette, Rebecca; Yockey, R. Andrew; Fulda, Kimberly
    Purpose: Health disparities between different racial and ethnic groups exist for many preventable chronic conditions, such as cardiovascular disease and diabetes. High- sensitivity C- reactive protein (hs-CRP) is a marker of systemic inflammation, and it is known that inflammation is one of the many components associated with physiologic deterioration, or chronic illness. Research has shown disparities in elevations of hs-CRP within different races and ethnicities. Furthermore, research has also demonstrated which factors can lead to elevations in hs-CRP within the general population. However, there is a need to determine factors and clarify relationships predictive of elevated HS-CRP for different racial and ethnic groups. The purpose of this analysis was to identify sociodemographic, health behavior, and clinical factors that predict hs-CRP by race / ethnicity. Methods: A secondary analysis of the 2017-2020 National Health and Nutrition Examination Survey (NHANES) was conducted. Briefly, the NHANES is a nationally representative survey assessing physical activity, chronic disease, and other health behaviors among adults 18 years of age and older in the United States. The outcome variable was hs-CRP levels, which was log-transformed due to non-normal distributions. Covariates included demographics (e.g., age, biological sex, education, marital status), insurance, BMI, sleep, depression, alcohol drinks, physical activity, and number of chronic conditions. Due to missing data, 5 datasets were imputed and combined in a multivariate manner using Rubin’s rules. Regression analyses were conducted stratified by race/ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, Mexican American, Other Hispanic, and Other/Multi-Racial) to determine significant risk factors. Analyses were weighted to be representative of the U.S. population. Results: The analytic sample consisted of 15,476 adults ages 18 years or older (M= 38.5,SE =0.19). Diverging patterns emerged regarding hs-CRP levels, such that significant risk factors included BMI, biological sex (female), and health status. For white individuals, identifying as female (b = 0.13), increased BMI (b = 0.07), and poor sleep (b = 0.07) were significant predictors of inflammation. Regarding Black individuals, increased age (b = 0.01), identifying as female (b = 0.19), and increased BMI (b = 0.07) were significant predictors of inflammation. Pertaining to Mexican American individuals, identifying as female (b = 0.44), reporting good/fair/poor health (b = 0.28), and increased BMI(b = 0.08) were significant predictors of inflammation. Good/fair/poor health (b = 0.33) and increased BMI (b = 0.07) were significant predictors of inflammation for Other Hispanic individuals, while never being married decreased the risk for inflammation (b = -0.45). For Asian individuals, increased poverty (b= 0.08) and increased BMI (b = 0.09) were significant predictors. Finally, for multi-racial individuals, identifying as female (b = 0.37) and increased BMI (b = 0.04) were significant predictors of inflammation. Conclusion: This study identified racial/ethnic differences in sociodemographic, health behavior, and clinical factors that predict hs-CRP. Understanding disparities in risks for elevated hs-CRP could help clinicians identify potential biomarkers and intervene to reduce the impact of elevated inflammation among racial/ethnic minorities. Future research should include other social determinants of health such as environment, shift work, and nutrition.
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    Social Needs Assessment in Women of Reproductive Age vs. the General Population
    (2024-03-21) Holley, Bethany
    Purpose The objective is to identify the most prominent social needs among women of reproductive age and how it impacts their health and ability to access health care. In 2018, the CDC reported that most preventable deaths among women of reproductive age are due to broader failures of social support. Despite comprising over half of the population and influencing the majority of healthcare decisions, there is minimal discourse within the industry regarding the distinct impact of social determinants of health (SDOH) on women. Methods Retrospective chart review of 1,478 completed social needs assessments among patients who visited the University of North Texas Health Science Center Central Family Medicine Clinic from June 2020 to December 2023. The PRAPARE (Protocol for Responding to & Assessing Patients’ Assets, Risks, & Experiences) screening tool, a nationally standardized tool created by the National Association of Community Health Centers, was used to assess social needs. The data was separated into two groups: reproductive-aged women 18-45 years old (288 patients) and the remainder of the study population (1,190 patients). The remainder of the study population was comprised of 752 females and 438 males, ranging in age from 1-90 years old. Descriptive statistical analysis was used to quantify the social needs among reproductive-aged women compared to the remainder of the study population. Results In each social needs category assessed by the PRAPARE screening tool, reproductive-aged women constitute a comparable or larger percentage of individuals impacted by the social need in question compared to the general population. Reproductive-aged women are most significantly affected by increased stress levels, inadequate healthcare access, difficulty obtaining childcare, unemployment, and domestic violence. Conclusions Reproductive-aged women have elevated and diverse SDOH-related needs, with notable disparities observed across race, ethnicity, and socioeconomic dimensions. In order to efficiently alleviate the effects of SDOH on reproductive-aged women, stakeholders must proactively invest in enhancing the capability of healthcare providers to identify and address SDOH-related needs. This includes actively involving reproductive health care providers, who often serve as the initial and primary point of contact within the healthcare system for women in this age group. As healthcare expenses in the United States continue to rise and disparities in health care access and outcomes persist, concentrating solely on clinical aspects of health proves inadequate. It is evident that effectively mitigating health disparities requires industry leaders to comprehend and allocate resources toward addressing the unique needs arising from social conditions.
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    Evaluating Equity in XGBoost Predictions of High Healthcare Expenditures for Older Women with Osteoarthritis in the United States
    (2024-03-21) Elchehabi, Sahar; Dehghan, Arshama; Pathak, Mona; Sambamoorthi, Nethra; Park, Chanhyun; Shen, Chan; Sambamoorthi, Usha
    Purpose: Osteoarthritis (OA) is a highly prevalent and debilitating condition among older adults. Studies suggest that women are more prone to develop symptomatic disease than men. OA is associated with high direct healthcare costs, attributable to its complex disease management. Furthermore, a small segment of this population may incur very high costs. Identifying these high-cost users is important for allocation of resources, cost containment, quality improvement, and population health management. However, current research in the prediction of high-cost users in OA using machine learning (ML) models is limited. Furthermore, ML model predictions of high-cost users must be equitable across sensitive attributes such as race and ethnicity and socio-economic status. This study investigated the leading predictors of high-cost users among older women with OA utilizing ML methods and the fairness of the ML algorithm in its predictions across subgroups of race and ethnicity, poverty, and education. Methods: A cross-sectional study was conducted using data from older women (age>65 years) with OA from the 2021 Medical Expenditure Panel Survey, a nationally representative survey of the non-institutionalized civilian households in the US. High-cost users were identified as having higher than the 90th percentile (>$39,388) in total healthcare expenditures. Key predictors were identified using interpretable ML model eXtreme Gradient Boosting (XGBoost) Classification and SHapley Additive exPlanations (SHAP). Overall model fit was evaluated with AUC, recall, and precision. Fairness was measured with demographic parity (equalization of odds, disparate impact, and equal opportunity) across racial and ethnic groups (Non-Hispanic White (NHW), Non-Hispanic Black (NHB), Hispanic ethnicity), education (no college and college) and poverty status (low income and high income). Counterfactual fairness was evaluated to ensure consistency in high-cost predictions between actual scenarios and counterfactual situations where individuals belong to different groups. Results: A higher percentage of Hispanic (12.2%) and NHB (14.4%) were high-cost users compared to NHW (9.0%). A higher percentage of older women without college education (10.7%) and with low income (11.2%) compared to those with college education (2.5%) and high income (5.2%) were high-cost users. The overall model fit was acceptable with AUC 0.81, recall 0.62, and precision 0.91. Multimorbidity, high school education level, and anxiety were the top 3 predictors of high-cost users. Prediction was lower among older women without college education (AUC = 0.80) and low income compared (AUC = 0.77) compared to overall prediction (AUC = 0.81). Demographic parity revealed little to no differences across racial and ethnic, education, and income groups. Conclusion: The fairness metrics indicated no bias in the predictions, likely attributable to the nationally representative nature of the survey sample and its large size. These findings need to be confirmed with other data that contain diverse populations. Leading predictors indicated that effective management of multimorbidity may reduce the risk of high-cost use in older women with OA.