Health Disparities

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    The mediation role of Sleep in the association Between Acculturation and Obesity in Hispanic Women aged 19-50 years
    (2020) Liu, Jialiang; Tao, Menghua; Wingard, Ann
    As Hispanics immigrants to the U.S. become acculturated, they face adverse health outcomes such as obesity. The prevalence of obesity is high in US Hispanic women. The association of acculturation with obesity has not been well investigated. This study's objective was to examine whether the association between acculturation and obesity was mediated by sleep in Hispanic women. Data from 2,415 Hispanic women (19-50 years) from the National Health and Nutrition Exam Surveys (NHANES) 2005-2016 were analyzed. Participants were categorized into overweight/obese or non-obese. Acculturation was measured by language spoken at home and country of birth. Sleep was measured by self-reported hours per night. Multi-variable adjusted logistic structural equation model was used for mediation analyses. All analyses were adjusted for sampling weights to account for the complex sampling design. Approximately, 72% of Hispanic women were overweight/obese. Overall, neither language spoken at home nor country of birth was not associated with overweight/obesity. However, associations varied by survey cycles. There was significance between language at home and overweight/obesity in NHANES 2009 and 2010 cycle. Country of birth was associated with increased odds of overweight/obesity in NHANES 2007 and 2008, 2009 and 2010, and 2015 and 2016. Sleep duration did not mediate the association between language spoken at home and country of birth with overweight/obesity in the overall population and subpopulations by cycle. Our findings suggested that country of birth and language acculturation might impact overweight/obesity in Hispanic women. Sleep duration did not mediate the associations in this population.
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    Evaluate the Association of the HPV Vaccination and Cervical Cancer Incidence Among Various Race and Ethnicities
    (2020) Fernando, Shane; Nair, Maya; Soomro, Zara
    Background: Human Papilloma Virus (HPV) is a sexually transmitted disease that causes cervical and oropharyngeal cancers. The HPV vaccine protects against serotypes 6, 11, 16, and 18. The current CDC recommendation for the vaccine is 2 doses if under 15 years and 3 doses if over age 15. The HPV vaccine has high efficacy in preventing HPV-related carcinomas. Despite availability of the vaccine many are not completing the vaccine series. Objective: Currently, African Americans and Hispanics have the highest frequency of cervical cancer, rates of new cancers, and cancer-related deaths. Understanding the racial and ethnic disparities that influence HPV vaccination coverage and cervical cancer incidence will help us improve care and reduce disparities. Methods: HPV vaccination rates amongst various races and ethnicities was collected from the CDC's National Immunization Survey (NIS). HPV vaccination administration quantities in male and female adolescents were collected from the NIS. HPV vaccination rates were then compared to one-dose versus series completion in genders and races/ethnicities. Results: HPV vaccine dose completion decreased substantially in African American, White, and Asian females. HPV vaccine rates in male adolescents increased across all races and ethnicities. Cervical cancer rates have decreased which indicate that the HPV vaccine is efficacious. Conclusion: Even though HPV vaccine awareness has increased, disparities in African Americans and Hispanics continue to exist at a greater rate than among those of other race/ethnicities. Promoting the HPV vaccine in these groups could help reduce HPV-associated cancers.
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    Evaluating Integrated Care and Mental Health Resources in Student-Run Homeless Clinic
    (2020) Mirochnitchenko, Alissa; DeMoss, Dustin; Douglas, Elizabeth
    Background: People with major mental illness have life expectancies 10-20 years shorter than expected, but this is not necessarily due to suicide, accidents, or violence. Even patients with mental illness who die of natural causes are likely to die at a younger age than the general population. Untreated mental health or substance abuse disorders in primary care settings are associated with treatment nonresponse, higher complication rates, and increased healthcare use. Integrated care is defined as co-located multi-disciplinary approach to care addressing both physical and mental symptoms in an outpatient setting. With this in mind we evaluated TCOM's homeless clinic resources in order to improve patient care by integrating mental health education and screening into the student-run clinic. Case Information: The clinic provides health screening services for the patrons of TrueWorth shelter. Most clinic volunteers are preclinical TCOM or PA students who reflect the Reporter of the RIME model of medical education (Reporter, Interpreter, Manager, Educator). Thus, mental health interventions must reflect the services offered and abilities of the students. Students equipped with mental health tools, such as PHQ9, screen patients and provide them printed lists of local mental health resources. Conclusions: Homeless populations experience higher rates of mental health conditions and substance abuse. These often contribute to homelessness or joblessness; and likewise homelessness can contribute to mental health conditions. If such conditions are identified and treated, patients can break the cycle. Providing students with the proper framework enables referrals to local resources and better patient care.
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    The Relationship of Healthcare Access to Routine Check-Ups in Males and Females Ages 18 to 24
    (2020) Gentry, Ashley; Hartos, Jessica; Gardner, Rachel; Ryan, Taylor; Fender, Mason; Thomas, Shelby
    Purpose: Routine check-ups are fundamental to preventative healthcare; however there have been conflicting findings regarding the relationship between healthcare access and routine checkup utilization, especially by gender. The purpose of this study is to assess whether healthcare access is related to routine check-ups in males and females ages 18-24. Methods: This cross-sectional analysis utilized 2017 data from the Behavioral Risk Factor Surveillance System across 5 states. Using multiple logistic regression by state, we assessed the relationship between healthcare access and routine checkups and gender after controlling socioeconomic, demographic, health related factors. Results: Across states, up to 2/3 of males and females reported having a routine check-up in the past year and about 2/3 of males and females reported having public or private health insurance. Cost did not preclude seeing a doctor in the past year for most males and females. Adjusted analysis across states showed that health insurance and cost were significantly related to routine check-ups for females, but not males. Conclusions: Our results indicated that routine check-ups are significantly related to healthcare cost and plan for young adult females, but not males. These study findings may be generalized to young adults in primary care. Up to 1/3 of young adults do not receive a routine checkup annually, therefore, it is important to educate young adult males on the importance of preventative care throughout life. We also recommend providers be conscious of cost when treating young adult female patients for routine check-ups.
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    Social Determinants of Health: Screening in a Primary Care Clinic
    (2020) Moorhead, Ava; Ebert-Blackburn, Didi; Petrus-Jones, Michael
    Purpose: Social determinants of health have increasingly become a focus in primary care. There is growing evidence that interventions in these areas may increase positive clinical health outcomes. The purpose of the current study is to increase documentation of, and emphasis on, these social determinants in a primary care clinic. The survey implementation process and the data which results will be used to address major social factors that may affect patients and that impact population health outcomes of the clinic. Methods: A modified version of a validated survey tool was incorporated into the clinic's EHR to track predetermined social health factors. ICD-10 codes were generated automatically into the patient chart based on survey responses. Qualitative analysis of administration environment and mode of survey delivery was conducted as well, including time for administration. Results: 28 surveys completed resulted in 11 new ICD-10 codes focused on social health factors. Survey timing was minimized in a face-to-face immediately prior to the provider encounter. Conclusions: The survey was found to be best administered in a face-to-face, private encounter which minimized administration time and enhanced communication of responses. This mode of delivery helped establish rapport with patients and gather culturally sensitive responses. ICD-10 Z-codes developed from social determinants of health will help guide providers to address such issues as part of each patient's health assessment and plan.
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    RAFT: Rapid Appraisal for Trafficking
    (2020) Alanis, Naomi; Grant, Kelley; Clark, Chelsea; Bell, Charles; Sunderji, Aman; Wombell, Tamsyn; Chisolm-Straker, Makini; D'Etienne, James
    Purpose: Many trafficking survivors report visiting a health care setting during their exploitation without being identified as victims of trafficking. There is only one validated screening tool to identify adults being trafficked; the Vera Institute for Justice's Trafficking Victim Identification Tool (TVIT). TVIT was designed for use by social work providers and takes 40-60 minutes to administer; it is not appropriate for the ED setting. Our goal is to validate a rapid screening tool for use in the ED to increase human trafficking victim identification. Methods: IES and JPS partnered with Icahn School of Medicine, Mount Sinai for the study. Data from four hospitals in the Mount Sinai system are used for initial validation and JPS data will be used for external multi-state validation. The study design utilizes randomized enrollment process, comparison of candidate questions to the validated standard (TVIT), psychometric analysis with criterion validation, and external validation. Well-trained volunteers administered both the validated TVIT and the candidate RAFT questions to patient-participants in the ED. This study is powered based on best estimate of trafficking prevalence at 1.2-1.4% of ED population. Results: JPS started enrollment May 2018; 2070 patients have been approached, 809 patients have been enrolled, and data collection continues. Current interim data indicates a 1.44% lifetime prevalence of trafficking in this population. Conclusion: Evidence suggests a unique opportunity for EDs to screen and identify trafficked individuals; a validated screening tool for ED use will improve screening and identification of trafficked individuals.
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    The Effects of Medicaid Expansion on Women's Health
    (2020) Kannan, Srijaa; Huang, Jacqueline; Saxena, Raina
    Purpose: The purpose of this review is to identify how Medicaid expansion has impacted women's health. Before the expansion, patients from all states could qualify for coverage based on factors such as income, household size, disability, and family status. When certain states expanded Medicaid, this allowed for coverage based solely on income, improving enrollment rates. Methods: A literature search through various journals was utilized using terms such as Medicaid expansion, women's health, and maternal health. The goal was to find resources regarding the intersection between Medicaid, Medicaid expansion, and women's health. Results: In addition to allowing more reproductive-aged women to enroll, Medicaid expansion is associated with an overall increase in coverage, quality of care, and services for women. Specifically, it increased coverage of preconception, perinatal, and postpartum care, while lowering maternal mortality rates. However, the effects of expansion on breast and cervical cancer screening rates is uncertain. Some studies showed an increase in cancer screening rates; however, those that showed no significant change related it to barriers to access and supply of primary care providers available. Conclusions: Medicaid expansion has brought about favorable outcomes in women's health. Overall the number of women eligible for Medicaid coverage in participating states has expanded. It has improved maternal health and mortality and may show positive trends towards increasing cervical and breast cancer screening rates. Further research on variables such as ethnic and racial disparities, access to care, and physician availability may provide further insight into the differences between expansion and nonexpansion states.
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    Does Alcohol Use Differ by Weight Status in Young Adult Females?
    (2020) Ninan, Jaison; Meadows, Jonathan; Goss, Ethan; Hartos, Jessica; Thompson, Feroza; Jensen, Bryn
    Purpose: Alcohol use and weight status have been linked in previous research; however, there is limited research focused on young adult females. Therefore, the purpose of this study was to assess whether alcohol use differs by weight status in young adult females. Methods: This cross-sectional analysis used 2017 BRFSS data for young adult females, ages 25-44, from Colorado (N=831), Minnesota (N=1592), North Dakota (N=512), Texas (N=1204), and Washington (N=1281). Ordered logistic regression analysis by state assessed the relationship between alcohol use and weight status while controlling for general health behaviors, health status, socioeconomic factors, and demographic factors. Results: About two-thirds of participants reported using alcohol (57-72%) and over half reported being overweight or obese (50-65%). Results of adjusted analysis across states indicated that alcohol use was inversely related to weight status. Furthermore, alcohol use was significantly related to physical activity. Conclusion: Overall, alcohol use was found to be significantly and inversely related to weight status in young adult females in four out of the five states. Since the data was from a population-based study, the results may generalize to young adult females in the primary care setting. Practitioners should always screen young adult females for alcohol use, weight status, and physical activity because of their high prevalence. Providers should assess for treatment of excessive alcohol use and maintenance of healthy weight status, referring to alcohol treatment programs and weight management specialists, as necessary. Patients should also be educated on the importance of physical activity.
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    Preliminary findings related to change in diet and physical activities among SHE Tribe participants
    (2020) Deahl, Claire; Spence, Emily; Chhetri, Shlesma; Dhakal, Eleena
    Purpose: SHE (She's Healthy and Empowered) Tribe is a community-based intervention designed to improve health and wellbeing of women by encouraging small lifestyle changes. Led by a trained peer leader, this is a 5-week program where participants talk about topics such as goal setting, self-care, movement, nutrition, and social support. During each session, participants are encouraged to set goals, do tasks needed to achieve their goals, and reflect on their process. SHE Tribe participants are also encouraged to adopt health behavior tracking practices. The purpose of this study is to explore adoption of diet and physical activities related practices including tracking among SHE Tribe participants. Methods: SHE Tribe participants complete face-to-face and online assessments during enrollment and exit which takes place upon completion of the 5 sessions. The questions included in the assessments range from general health, diet, physical activity, tracking behaviors, stress management, sleep patterns, social support, etc. Results: Preliminary analysis of pre and post data showed that the diet quality improved among participants along with improvement in the number of participants meeting recommended levels of physical activity. We also found an increase in the mean number of both physical activity and diet-related tracking behaviors. Conclusions: Our preliminary findings showed a positive change in overall diet and physical activities among SHE Tribe participants. We also found an increase in tracking behaviors which may reinforce positive lifestyle changes. These promising findings warrant further testing of the SHE Tribe model.
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    The Challenges of Transition from Pediatric to Adult Care of Individuals with Sickle Cell Disease
    (2020) Bowman, William; Fernando, Shane; Viju, Steffy
    Purpose: Sickle Cell Disease (SCD) used to be considered a childhood disorder, but with earlier diagnosis and more effective treatments, a large majority of patients with SCD are living past 18 years of age. This has created challenges regarding transition of care from pediatric to adult care. Tarrant County itself has seen a rise in adult SCD patients visiting Emergency Departments when compared to Dallas County. The purpose of this project is to present the need for comprehensive care for adults with SCD in Fort Worth and to propose possible options on how to implement an effective transition program. Methods: A website,, was used to collect information on steps for an effective transition. A comprehensive online review was also done to collect information on established and successful adult sickle cell programs in the United States. Results: The Six Core Elements, proposed by, is a structured process that can be customized for use and applied to many different types of transition care models and settings. An Adult Sickle Cell Clinic in Milwaukee, Wisconsin and the St Jude-Methodist Transition Clinic in Memphis, Tennessee revealed various details for an effective transition. Conclusion: The increasing number of adult patients with SCD seeking care from emergency departments in Tarrant County has raised the issue about a lack of comprehensive care for these patients. Implementing a successful transition process is dependent on cooperation from both pediatric and adult practices and/or health systems, and the early and ongoing engagement of parents and young adults.
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    An Assessment of Non-Consensual Sexual Experiences Among Men
    (2020) Griner, Stacey; Aiken, Julia
    Social media movements exposed the routine sexual victimization of women; however, the stories of male sexual assault survivors are still left largely unheard and untold. The Centers for Disease Control and Prevention estimated that 1 in 6 men experience childhood sexual abuse, and 1 in 21 men have been forced to penetrate someone else during their lifetime. However, little research explores the individual-level characteristics associated with sexual victimization of men. This study assessed the sociodemographic factors of men that report non-consensual sexual experiences. We analyzed data from the 2011-2017 National Survey of Family Growth, a cross-sectional, nationally representative survey. The sample was delimited to those who reported any type of sexual activity and were between the age 18 to 49 years (N=11,294). The sample was stratified into sexually victimized and non-sexually victimized to perform weighted frequencies and Chi-Square tests amongst sociodemographic variables. In this sample, 31.0% of men reported experiencing a non-consensual experience. Men that reported victimization debuted sexually at a significantly younger age (M=16.8 years, SE=0.22) compared to non-victimized men (M=17.2, SE=0.22) (p< .0001). Significant differences in victimization appeared by race/ethnicity (p< .0001), childhood family structure (p< .0001), percent of federal poverty level (p< .0001), level of education (p< .0001), and sexual orientation (p< .0001). Our findings suggest that men experience a high prevalence of non-consensual sexual encounters, belying the cultural silence on male experiences of sexual violence. These estimates of demographic inequities can inform targeted interventions for survivors.
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    "To be comfortable in their own skin": Preliminary findings related to improved body positivity among SHE Tribe participants
    (2020) Spence, Emily; Chhetri, Shlesma; Ayebaze, Anthea; Dhakal, Eleena; Poleon, Suprena; Deahl, Claire
    Purpose: SHE (She's Healthy and Empowered) Tribe is a wellness program that encourages women to make healthy lifestyle choices. The goal of the program is to promote accountability, self-awareness and reflection, and positive growth. Over the course of five weeks, participants work on goal setting, stress management, movement, nutrition, and social support. Methods: Pre and post surveys were administered to participants which gather information on health habits as well as self-efficacy and body appreciation, through both in-person paper and electronic assessments that ask about current health behavior choices. The surveys include both open and closed ended questions. Information gathered from these surveys was analyzed for change in process, outcome and impact of the program. Results: Preliminary findings demonstrate that participants increased body appreciation and improved overall quality of life after participating in the SHE Tribe program. Participants also reported improved self-awareness and adoption of self-care practices. Participant ratings and qualitative responses show high levels of satisfaction with the program. Conclusions: These findings offer a preliminary indication that participants increased their positivity about their bodies. As a program geared towards improving women's health through lifestyle changes, enhancing body positivity can be an essential step towards increasing self-confidence to improve one's belief that she is in control of their health. Positive participant satisfaction responses suggest that the format of the program is succeeding in reaching participants.
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    (2020) Rasu, Rafia; Karpes Matusevich, Aliza
    Objectives: Assess the association between the inability to obtain prescription medications and future medical expenditure. Methods: We included participants older than 65yrs from the 2007-2017 Medical Expenditure Panel Survey longitudinal data files. Expenditures were updated to 2017 values using the Personal Consumption Expenditures index. We compared those who did and did not report being unable to get necessary prescription medication in terms of demographics and total logged healthcare expenditure the following year using chi-square and t-tests and linear regression. Results: Our cohort (n=19,566) was predominantly female (57.1%), white (71.3%) and non-Hispanic (85.6%) with a mean age of 73.9 (SD:6.6) and 2.8 comorbidities(SD: 2.1). 360(1.8%) people were unable to obtain prescription medication. In both years of the survey this group had significantly higher adjusted prescription medication (Y1: $4,407 (SD:6,195) vs. $2.688 (SD:5,220) Y2: $4,824 (SD:6,729) vs. $2,915 (SD:5,724)) and healthcare expenditure (Y1: $14,595 (SD:17,970) vs. $10,558 (SD:18,793) Y2: $15,885 (SD:18,334) vs. $11,574 (SD:19,465)). However, being unable to get necessary medications was not significantly associated with total health care costs in the second year of the survey when controlling for baseline covariates and first year healthcare costs. Age, race, ethnicity, education level, perceived health status, number of comorbidities and being uninsured in the second year were correlated. Conclusion: The study points to socioeconomic drivers of healthcare expenditure. It is encouraging that < 2% of older adults report being unable to obtain prescription medication and future research will assess if medication adherence is related to categories of future expenditure.
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    Identification of Triple Negative Breast Cancer Epidemiological Risk Factors for African American Women
    (2020) Del Valle, Michelle; Hayatshahi, Sayyed; Liu, Jin; Radler, Charlene; Morid, Mohammad; Calcagno, Alexa
    Purpose: Triple Negative Breast Cancer (TNBC) is a basal breast cancer subtype lacking progesterone receptor, estrogen receptor, and HER2 gene expression. TNBC has a poor prognosis with limited treatment options, and it occurs at higher rates in African American women compared to White American women. The purpose of this project was to classify race-dependent socioeconomic risk factors and to initiate a guideline for TNBC screening in African American women. Methods: We used the data from the Surveillance, Epidemiology, and End Results Program (SEER) of the National Cancer Institute. Our dataset included 35,976 female TNBC patients with 441 attributes documented in the United States. Top attributes for TNBC were specified for female African American patients through applying machine learning principles and optimization algorithms. Traditional statistical techniques were used to validate the key risk factors identified via machine learning. The top attributes identified represent socioeconomic, phenotypic, and epidemiologic factors. Results: The top factors related to African American TNBC patients determined in machine learning and descriptive statistics included marital status at diagnosis, age at diagnosis, and insurance status. Specifically, single status, lack of private insurance, and younger age at diagnosis corresponded to worse prognosis and increased mortality. Conclusions: Based on the top attributes identified, African American women would benefit from screening for TNBC beginning in their mid-late 40s, with particular attention given to single and uninsured women. Such screening methods might correspond to earlier diagnosis, prevention, and treatment and decrease rates of incidence and mortality of TNBC in African American women.
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    PRECISION Participant Pain Scores and Opioid Use According to History of Depression, Demographics, and Antidepressant Use
    (2020) Wolstein, Austin
    Purpose American College of Physicians and CDC guidelines for chronic pain advocate for noninvasive techniques and nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapies. Duloxetine or tramadol are recommended second line pharmacologic therapies and opioids should be considered only if potential benefits outweigh the risks. We report associations of pain intensity scores, race, depression, and medication usage on predictive values for chronic low back pain (CLBP), using data from 426 patients within the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION). Methods CLBP intensity was classified as mild-moderate (0-6) or severe (7-10) based on numerical rating scale (NRS). Logistic regression was used to compute odds ratios and 95% confidence intervals (CIs) for associations between depression and the following predictor variables: demographics, pain intensity, and medications. Means and 95% CIs were computed according to reported use of antidepressants, tramadol, other opioids, NSAIDs, and according to age, race, ethnicity, and gender. Hypotheses were assessed at the .05 level of statistical significance with two-sided testing. Results Patients reporting a history of depression were more likely to use opioids and have higher NRS scores. African-American women who reported a history of depression taking both opioids and antidepressants displayed the highest NRS scores. Conclusions Depression was a statistically significant risk factor for higher NRS scores and opioid use. Additional studies of the effects of depression, use of antidepressants, concomitant use of opioids, NSAIDS, and other medications are warranted to determine optimal therapies for chronic pain sufferers.