Health Disparities

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    Can Trust in Pharmacists Improve When They Have Complete Health Records?
    (2023) Madunezim, Quentin; Oranu, Chukwuezugo; Hodge, Crystal
    Intro: Pharmacists rank third amongst U.S. professionals for honesty and ethics. As one of the most accessible healthcare fields, we hypothesized that Since Ccommunity pharmacists with additional access to patient medical records would improve the pharmacist’s ability to conduct MTM and subsequently strengthen the patient-pharmacist relationship. Methods: This is a survey study administered as part of a randomized controlled trial (NCT03437694)e with the primary purpose of the impact of medication therapy management (MTM) on the health of persons living with Human Immunodeficiency Virus (HIV). As part of the larger clinical trial, participants were randomized 1:1 into the intervention arm (MTM with pharmacist access to patient health records) or the control arm (MTM without pharmacist access to patient health records). Patient health records were defined as updated labs, imaging results, and notes from their primary care provider. The inclusion criteria were African American, adults, and comorbid conditions including HIV on antiretrovirals, and the presence of hypertension and/or diabetes. The purpose of this survey study is to determine if there is a difference in the degree of participant trust based on the trial arms. Additional inclusion criteria for this study was completion of at least 5 out of the 9 scheduled visits. Participant surveys were excluded if they had unanswered responses. The study was approved by the University of North Texas Health Science Center’s IRB (#1436643/2018-094) which included the administration of participant surveys. The survey was an unvalidated, contained 43-item questionnairesassessed on a 5-point Likert scale (1 = Strongly Agree to 5 = Strongly Disagree), and administered at every MTM visit. Four questions related to participant trust were extracted from the larger survey administered at the fifth study visit. Reverse coding was used given the structure of the Likert scale and applied so that higher values represented better outcomes. For each participant, an average of the responses to the four questions was calculated. All categorical data were analyzed with descriptive statistics. Since patients were not matched, an independent t-test was used to compare the survey scores between arms. Results: A total of 58 participants were included with an average age of 55 years. The majority of the surveys were from participants assigned to the control arm (57%). The average trust score for the intervention arm was 4.82 ± 0.39. The average trust score for the control arm was similar at 4.82 ± 0.41 (p = 0.99). Conclusions: The results demonstrated an overall strong degree of trust in pharmacists conducting MTM. There was no statistically significant difference in participant’s attitude or expression of trust towards the capability of the community pharmacist regardless of pharmacist access to additional medical records. The lack of statistical difference could be explained by the small sample size, unmatched participant characteristics, and the overall high agreement signifying an already trusting relationship between participant and pharmacist. This is in line with other data suggesting that the field of pharmacy is one of the most trusted fields in healthcare.
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    Health Equity Implications of Transgender Policies in the United States: A Legal Epidemiology Approach
    (2023) Webb, Nathaniel; Kline, Nolan; Johnson, Kaeli; Yording, Hayley; Griner, Stacey; Brunell, David
    Introduction Transgender (trans) populations experience worse health outcomes compared to cis-gender populations, including higher rates of poor mental health, experiences of medical bias, and communicable diseases. These health disparities are broadly influenced by the political context within individual states that can perpetuate social exclusion. In the last five years, there has been a sharp increase in exclusionary legislation related to trans individuals that can deepen health inequality and exacerbate poor health outcomes. Using a legal epidemiological approach, we conducted a policy scan of state-level legislation in the United States to determine geographic distribution, frequency, and whether the legislation was trans affirming and/or exclusionary. Methods We searched the Westlaw policy database to identify proposed legislation in U.S. states between 2017-2021 using search terms related to "transgender.” The initial search identified 1280 results, of which, 698 proposed bills were included in the final analysis. Five researchers reviewed the proposed legislation and categorized each bill into "affirming” or "exclusionary” categories. Using a priori themes identified in the grey literature and refined among the research team, bills were further categorized by the theme of the legislation into 11 categories: athletics, bathrooms, administrative changes, affirmation care, religious claims, recognition, rights in the healthcare field, training revisions, criminal justice reform, education and school, and government augmentation. These categories were used to calculate affirming density, exclusionary density, and inclusivity scores and corresponding maps for legislation related to trans populations in each state. Results Of the 698 policies reviewed, 567 (81.23%) were affirming of trans identities while 131 (18.77%) were exclusionary of trans identities. Affirming legislation included policies related to government augmentation (20.81%), education/school (18.34%), administrative bills (18.17%), criminal justice reform/legal protections (15.34%), rights in the healthcare field (11.46%), training revisions (10.05%), recognition (4.94%) affirmation care (0.71%), and athletics (0.18%). Exclusionary legislation included policies related to athletics (58.78%), affirmation care (24.43%), bathrooms (7.63%), education/school (3.82%), religious claims (2.29%), administrative changes (1.53%) and rights in the healthcare field (1.53%). Affirming legislation was most prominent in the West Coast, the Northeast, and parts of the Midwest. Conversely, exclusionary legislation was highly prevalent among Southeast, South Central, and Mountain West regions. Discussion This study laid the foundation for further analysis of the political context and its influence on trans health. Exclusionary and affirming density maps indicate vastly different political contexts for trans individuals depending on US state. Such political contexts can contribute to social exclusion of trans individuals that exacerbates poor health outcomes. Further, the magnitude of legislation proposed was starkly different between affirming and exclusionary policies. Exclusionary policies focused on criminalization of trans-related issues such as gender-affirming care. Comparatively, affirming policies were largely focused on forms of representation related to local boards or governing committees (government augmentation). Representation of LGBTQ+ communities in government is incredibly important but may not negate the harm caused by the criminalization of trans-related care. Future research is needed to investigate legal etiologies of health disparities seen in trans populations compared to cisgendered populations.
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    Association of Race and Receiving Mental Health Counseling in Patients Diagnosed with Depression
    (2023) Powell, Dillon; Mayfield, Katherine; Kellerlee, Joel; Lee, Hannah
    Context: High prevalence of depression in the United States population is a rising issue, which warrants the need for understanding how to best target behavioral therapy as a treatment option for populations who are least likely to have received or to seek out such intervention. Purpose: To determine if there is a significant relationship between race and frequency of mental health counseling as a treatment option in patients with depression. Methods: This cross-sectional study included 949 patients diagnosed with depression, retrieved from the 2018 NAMCS (National Ambulatory Medical Care Survey) database. These patients were stratified by race as given in the NAMCS variable as "White”, "Black”, and "Others”. Of those 949 patients, 97 subjects sought out mental health counseling. We performed statistical analyses to determine if race was a predictor for seeking out mental health treatment. Results: An ANOVA statistical analysis demonstrated a significant difference in those who sought out mental health counseling and race (p = .009) amongst those patients diagnosed with depression. Age (p <.001) was another significant factor affecting whether these patients sought mental health counseling. 12/42 "Other” subjects (9.1%, p <.001) with depression sought mental health treatment, followed by 9/69 Black subjects (13%, p = .024), followed by 76/838 White subjects (9.1%, p <.001). Conclusions: The results contradicted our initial prediction, which anticipated that the white population would show higher rates of receiving mental health counseling than black and other race populations. We attribute these findings to the differences in severity and perception of depression symptoms among different races. Limitations to the study include sample size availability, inconsistencies in what each physician constitutes as mental health treatment, coding inaccuracies, and confounding variables including socioeconomic status and age.
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    Transgender Healthcare and The Impact of Increased Politicization of Medicine
    (2023) Gill, Lily; Kline, Nolan; Navid, Daniel; Rice, Ellie; Webb, Natey; Johnson, Kaeli; Griner, Stacey; Neelamegam, Malinee
    Purpose Transgender (trans) people have a unique set of health needs that are often misunderstood and/or ignored in health settings. Such misunderstandings contribute to mental and physical health disparities when compared to the cisgender population, such as increased rates of anxiety, depression, suicide, substance abuse, adverse cardiovascular events, and other chronic health conditions. Addressing these disparities requires greater access to gender-affirming care (GAC) with providers who are comfortable and knowledgeable about trans individuals’ unique health needs. However, recently there has been an increase in anti-transgender legislation across the United States. This raises questions about provider regulation and ability to provide culturally appropriate care to trans patients, and potentially widening access and care disparities among trans individuals. Future providers, including medical students, who are being trained during moments of heightened anti-transgender politics, may not feel sufficiently prepared to care for trans patients. This exploratory study examined 1) current medical students’ knowledge and attitudes towards treating trans patients 2) gaps in transgender-focused content in medical curricula, and 3) medical trainings and their degree of impact on transgender healthcare. Methods A literature review was conducted by searching scholarly databases including PubMed using the terms related to transgender health, policy, medical students, gender-affirming care, health providers, and gender dysphoria. Articles that were 1) published after 2014 2) in English, and 3) available as full text were included. The search yielded 52 articles that were then reviewed for content on medical students’ knowledge and attitudes about trans patients, gaps in medical curricula, and perceived efficacy of trans-focused trainings and educational interventions. Results Existing literature suggests that trans health disparities are largely related to provider lack of knowledge and training. Despite potentially positive attitudes regarding this population, most medical students feel their curricula lacks transgender-centered content. This includes diagnosing gender dysphoria, hormone-therapy, puberty blockers, and sex reassignment surgeries. Although some students may feel knowledgeable about trans individuals’ needs overall, many report they still feel ill-prepared to work with trans patients. They request more clinical exposure to gain confidence with proper history taking and interview skills. When assessing the training modalities preferred by medical students, interactive interventions including direct communication with trans patients yield the greatest increase in perceived confidence levels. The most recommended training modalities for practicing physicians are attending professional conferences, acquiring direct clinical mentorship, and implicit bias self-awareness workshops. Conclusion This synthesis of current research highlights the need for increased trans-focused support in medical education, which will contribute to improving overall health outcomes, ease barriers, and ameliorate disparities for transgendered persons. In the current political context, physicians who provide GAC are faced with a unique set of social and legal challenges. Government intrusion of clinical decision-making may force physicians to forgo their obligations to transgender patients, thereby directly eliciting harm to an already marginalized population. Accordingly, current and future providers may need to engage in trans-focused advocacy efforts.
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    Review of an Advanced Case of Psoriatic Arthritis and Barriers to Management of Chronic Disease in the West Texas Region
    (2023) Martin, Delaney; Joseph, Matthew; Iloani, Nwamaka Amy; Tadesse, Meron; Hadley, Lesca; Allsopp, Leslie C.
    Background: Psoriatic arthritis is a debilitating, inflammatory musculoskeletal spondyloarthritis associated with the skin condition psoriasis that affects the hands, feet, spine, and other parts of the body. Nearly 80% of patients develop the associated arthritis after skin lesions of psoriasis develop. Management of psoriatic arthritis can be difficult, with severe variants recommended to receive specialized care from a rheumatologist for optimal treatment. The clinical case that will be discussed refers to a patient presenting with psoriatic exacerbation, which progressed from skin lesions to psoriatic arthritis with unmanaged pain. Despite the severity of this progression, he received minimal education on psoriatic arthritis management. Case Presentation: A 34-year-old male presented to clinic with a primary complaint of pain for uncontrolled psoriatic arthritis that had been diagnosed one year prior, two years after an original diagnosis of psoriasis. He reports the diagnosis of psoriatic arthritis was made after diffuse rashes spread over his body and extensor surfaces with increasing joint pain. At the clinic, the patient complained of weakness in his extremities; severe pain at elbow, ankle, knee, and toe joints bilaterally; a diffuse erythematous rash particularly at the ankles; and difficulty with daily activity due to pain. Notable physical exam findings included a personal history of psoriasis, joint pain, nodules growing past the distal interphalangeal joint of his hands and feet along with dactylitis and nail dystrophy consistent with psoriatic arthritis. Based on Classification for Psoriatic Arthritis criteria (CASPAR), he would be due to a score above 5 classified as having psoriatic arthritis. He has a known history of epilepsy, spinal stenosis, generalized anxiety disorder, chronic PTSD, and type 1 bipolar disorder. Patient reported recurrent methamphetamine use along with frequent use of marijuana for pain control. His social history was significant for lack of employment and symptoms worsening while uninsured. He stated an inability to attend scheduled appointments due to lack of transportation, the distance from Terlingua to the clinic in Alpine, TX, and inability to obtain telemedicine visits with his current provider. Conclusion: This case study on management of advanced psoriatic arthritis examines the health disparities faced by patients in rural west Texas regions, including lack of patient education, access to qualified rheumatologists, and adequate resources to manage disease exacerbation. A literature search on PubMed was conducted to clarify the current standard of care for treatment of advanced psoriatic arthritis, as well as current restrictions in management within the West Texas area. For social determinant factors, the social vulnerability index for west Texas regions was reviewed using public Center for Disease Control and Prevention data to note qualified health centers for this level of need and found appropriate services are lacking within the town of Terlingua and its neighboring areas. In addition to the healthcare team, an appropriate and safe environment for those suffering with psoriatic arthritis also includes stable infrastructure, social support, and public transportation. Without public health measures and capable providers, there are increased barriers to care of chronic disease for those living in rural areas like Terlingua.
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    LGBTQ+ Young Adults and Likelihood of Receiving Hypothetical Chlamydia and Gonorrhea Vaccines
    (2023) Lemuz, Tiffany; Johnson, Kaeli; Kinard, Ashlyn; Terrillion, Ryan; Kline, Nolan; Griner, Stacey
    Background Sexual and gender minority (SGM) young adults (those identifying as lesbian, gay, bisexual, transexual, and/or non-binary; often known as LGBTQ+) face a number of health disparities and are among the most at risk of acquiring sexually transmitted infections (STIs) such as chlamydia and gonorrhea. Candidate vaccines against chlamydia and gonorrhea are under development, but an understanding of the likelihood of receiving future vaccines among SGM young adults is vital to promote uptake among these populations. Prior research of STI vaccine acceptability and likelihood, such as that of the human papillomavirus vaccine series, has shown healthcare provider recommendation to be a strong driver of uptake among the general population. The likelihood of the SGM young adult population receiving potential chlamydia and gonorrhea vaccines, however, has yet to be explored. The purpose of this pilot study was to examine the likelihood of SGM young adults receiving future chlamydia and gonorrhea vaccines. Methods Sexually active young adults between the ages of 18 to 24 were recruited to participate in an online survey. Here, we present a sub-analysis of the SGM young adults (n=14) who completed the survey. Items included likelihood of receiving a hypothetical: chlamydia vaccine, chlamydia vaccine if it was recommended by a physician, gonorrhea vaccine, and gonorrhea vaccine if it was recommended by a physician (response options: not very likely to extremely likely, five-point scale). Univariate analyses were conducted using SPSS. Results Participants included 12 individuals identifying as gender non-conforming and 2 identifying as transgender, with mean age of 20.9 years. Only 21% (n=3) of participants were extremely likely to be vaccinated for gonorrhea, and this increased to 36% (n=5) when the vaccine was recommended by a healthcare provider. Similarly, only 21% (n=3) of participants were extremely likely to be vaccinated for chlamydia, which also increased with a recommendation from a healthcare provider to 43% (n=6). Conclusion Results indicate low likelihood of receiving both chlamydia and gonorrhea vaccines among this small sample of SGM young adults. Likelihood of receiving both chlamydia and gonorrhea vaccines increased, however, with provider recommendation, indicating a reliance upon healthcare providers to aid in informed decision making regarding STI vaccines among this vulnerable population. Educating clinicians on the disparities as well as the tailored needs of SGM young adults surrounding chlamydia and gonorrhea infection rates and vaccination should facilitate provider recommendation and subsequently increase likelihood of chlamydia and gonorrhea vaccine uptake among SGM young adults. Additionally, to address overall low likelihood, further interventions, such as inclusive messaging targeted to SGM young adults may be necessary. Future studies would benefit from further exploration of this topic with larger samples, comparisons to cisgender and heterosexual young adults, and identification of additional potential barriers to STI vaccine acceptability among this population.
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    A Cross-sectional Study on Healthcare Barriers Experienced by WellMed Patients at the University of North Texas Health Science Center Geriatric Clinic
    (2023) Martinez, Maria Francesca Ysabelle; Ngo, Wayne; Garfield, Tyson
    WellMed is Medicare advantage plan geared towards helping aging patients receive high quality healthcare at low cost. WellMed is available to Medicare eligible patients and dual eligible Medicare/Medicaid in Texas or Florida, with the University of North Texas Health Science Center (UNTHSC) geriatric clinic being one of the few centers in the area accepting the insurance. During the pandemic, it has become clear that access to care is a barrier for aging and underinsured patients, and a better understanding of what the barriers these patients face will help facilitate improved quality of care. A cross-sectional survey using Qualtrics was administered to WellMed patients at the UNTHSC geriatric clinic during regular clinic hours from June-July 2022. A total of 36 in-person surveys were administered and completed. The self-reported survey consisted of 23 multiple choice and fill-in questions that elicited information on wellness and potential healthcare barriers. A comparison between each variable and patient zip code was made. Looking at the responses to patient perceived healthcare barriers, 59.4% of respondents reported no barriers, 21.2% stated location of clinic, 12.1% lacked transportation, 12.1% found the appointment system difficult to use, and 6.1% had inadequate finances. Of note, incompatible clinical hours and lack of support for languages other than English were not perceived as barriers. For the fill-in "other barriers not listed” option, 5.6% stated the telephone system not being adequate for communication to the staff and doctors, and 2.8% cited problems with the patient portal. A total of 24 different zip codes were collected. When correlating each barrier with zip code, clinic location and lack of transport correlated with areas on the edge of Tarrant County. No particular relationship between zip code and other outcome measures were observed. Access to care is a social determinant of health that is cited as a cause of decreased health outcomes. In Tarrant County 22% of adults are uninsured and the ratio of primary care physicians to patients is 1:1690. This study elucidates health barriers WellMed patients in the county are facing. Addressing these barriers patients can experience improved quality of healthcare and easier access to necessary care.
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    HPV and Other Vaccination Rates in Texas: Association with Racial and Ethnic Distribution
    (2023) DePlaza, Maya; Dudhia, Amil; Freguson, Samuel; Basha, Riyaz
    Abstract Presenter: Maya DePlaza Authors: Maya DePlaza, Amil Dudhia, Sam Ferguson; Riyaz Basha, Title: HPV and Other Vaccination Rates in Texas: Association with Racial and Ethnic Distribution Background: Human Papilloma Virus (HPV) is a sexually transmitted disease responsible for ~70% of cervical cancer worldwide and can result in genital warts, anal, penile, and oropharyngeal cancers. Since the adoption of HPV vaccines, high-risk HPV incidences have decreased by 50%1. Vaccination is recommended from ages 11-26 and requires 3 doses to be up to date. While vaccination rates have increased, racial and ethnic minorities are less likely to complete the series, with rates of initiation and completion particularly low amongst African American adolescents2. Objective: This project examined the association between rates of HPV and other regularly recommended vaccines at the national, state-wide, and county level with consideration given to racial and ethnic distribution. Methods: Data was collected from the Centers of Disease Control and Prevention (CDC) and the National Immunization survey. Vaccination rates were compared between HPV, Tdap, and MenACWY vaccines at the national, state-wide, and county level3. Racial and ethnic makeup was also compared in these regions4. Results: When compared to the Tdap and MenACWY vaccines, vaccination rates for HPV (UTD and ≥1 dose) were significantly lower across national, state-wide, and county levels. The national vaccination rate for HPV UTD and ≥1 dose were 48.6% and 65.5% while the rates for Tdap and MenACWY vaccinations were 88.7% and 85.1%. Additionally, Texas had an overall lower vaccination rate of 39.7%, 57.8% and 83.2% for HPV UTD, HPV ≥1 dose, and Tdap, respectively. Texas county vaccination rates were lowest in Dallas County with HPV UTD at 35.7%, HPV ≥1 dose at 54.5%, and Tdap at 77%. Dallas county has the highest percentage of African American and Hispanic residents when compared to other major Texas counties, Texas, and national average. The non-white population in Dallas county makes up 48.5% while it is 32.3% and 28.2% at the state and nation level. Conclusion: While HPV vaccine rates have increased since its induction in 2006, it is still among the lowest vaccines received across all populations. This study suggests that there is a correlation between vaccination rates and racial/ethnic distributions. African Americans and Hispanics at the national and county level were shown to have the lowest vaccine rates, especially African American girls. Further analysis is required to determine the source of such health disparities and further links to socioeconomic factors. References: Jeudin P, et al. Race, ethnicity, and income factors impacting human papillomavirus vaccination rates. Clin Ther. 2014 Jan 1;36(1):24-37. doi: 10.1016/j.clinthera.2013.11.001. PMID: 24417783. Hirth J. Disparities in HPV vaccination rates and HPV prevalence in the United States: a review of the literature. Hum Vaccin Immunother. 2019;15(1):146-155. doi: 10.1080/21645515.2018.1512453. Epub 2018 Sep 6. PMID: 30148974; PMCID: PMC6363146. Boersma, Peter; Black, Lindsey. "Human Papillomavirus Vaccination Among Adults Aged 18−26.” DHHS Publication. Center for Disease Control and Prevention. "Human Papillomavirus (HPV) Vaccination & Cancer Prevention.” CDC, July 2022,
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    Oral Health Disparities among LGB and Non-LGB Individuals in the United States, 2007-2016
    (2023) Patterson, Alyssa; Nguyen, Uyen-Sa; Yockey, Andrew
    Purpose. Although oral health in America has generally improved over recent decades, health disparities in the field have remained an issue for several marginalized groups, one such being lesbian, gay, and bisexual (LGB) individuals. Few studies have investigated oral health outcomes in LGB individuals in comparison with their heterosexual counterparts. As such, the aim of this study was to examine potential oral health disparities among a national sample of American adults and investigate sex-differences in the association between sexual orientation and poor oral health. Methods. We used pooled data (2007-2016) from the National Health and Nutrition Examination Survey (NHANES) for men and women aged 18-59. Multiple imputation methods were used to impute missing data. Multiple logistic regression models were used to examine the association between sexual orientation and self-reported oral health, both overall and separately for men and women. Results. A total of 20,298 responses were included in this analysis. Compared with heterosexuals, LGB individuals had higher odds of reporting poor oral health than heterosexuals in both the unadjusted (OR = 1.20 95% CI = 1.04-1.38) and adjusted (OR= 1.21 95% CI 1.04-1.40), combined analyses. In the unadjusted sex-stratified analyses, sexual orientation was found to have a statistically significant association with poor oral health in females (OR= 1.51 95% CI = 1.26-1.79). After adjusting for covariates, women who were LGB had a 38% statistically significant increased odds of having poor oral health compared with their heterosexual counterparts (OR= 1.38 95% CI 1.14-1.67). Sexual orientation was not associated with poor oral health in males, with adjusted odds close to null comparing LBG men with their heterosexual counterparts (OR = 0.98, 95% CI = 0.74 - 1.29). Conclusion. This study explored oral health disparities among a large national sample of LGB Americans. Widening disparities continue to persist among minority populations, despite recent progress made in oral health settings. The findings in this study add to the information base of disparities prevalent in the field of oral health and may inform future interventions and public health frameworks.
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    Calculating Average Transit Times to Estimate Health Impacts in South Dallas
    (2023) Gomez Pinedo, Pamela; Vargas, Cristian; Dodgen, Leilani; Allison, Patricia; Kitzman, Heather
    Purpose: Access to reliable transportation remains a significant social determinant of health, with far-reaching implications for employment, physical activity, food security, nutrition, and access to care. In Dallas, the National Equity Atlas estimates 1 in 10 households do not own a personal vehicle. These estimates worsen for households of color—nearly 1 in 5 Black households in Dallas lack a vehicle. The Baylor Scott & White Health & Wellness Center (BSWHWC) provides primary care and preventive health services for low-income, predominantly Black and Hispanic populations in South Dallas’s Frazier neighborhood. Over 1 in 4 residents in this neighborhood do not have access to a vehicle. Studies on barriers to healthcare access have cited lack of vehicle access and extended travel times as significant reasons for missed appointments and poorer health outcomes. The Integrated Population Health Trial (I-POP) is designed to evaluate if Community Health Worker (CHW) navigation helps individuals improve their health compared to individuals receiving usual care at BSWHWC. CHW navigation involves monthly meetings with a CHW over 10 months, to connect participants to resources and utilize motivational interviewing to promote participant choices toward health improvement. Participants without a car are hypothesized to have longer public transit travel time and more absences for CHW appointments. This analysis identifies the extent and impact of transportation barriers for research participation in I-POP. Methods: Adult participants living within 10 miles of the BSWHWC were recruited for I-POP through flyers at BSWHWC and community centers. Participants completed informed consent and baseline measures, then were randomly assigned to either the intervention (receiving CHW monthly navigation) or usual care. Participants were included in this study if they were assigned to the intervention and relied on public transportation. Twenty-five of 100 participants met inclusion criteria. Street addresses were batch-fed through a public transit directions application programming interface (API) to generate average amount of time spent traveling to the BSWHWC for monthly CHW sessions at any possible appointment times (Monday-Saturday, 8:00am-4:30pm). Session attendance followed a somewhat uniform distribution and average travel time was moderately right-skewed. However, deviations from normal could not be fixed through transformation due to small sample size. To examine the relationship between CHW appointment attendance and average travel duration, a linear regression model was run controlling for age, gender, race, and income level. Results: Preliminary results indicate the average travel duration time for participants is not significantly related to participants’ attendance at CHW appointments (r=0.000534, p-value= 0.2390). Age and race showed minimal impact on session attendance, while being female showed a stronger positive association with session attendance (r=-2.90294, p-value=0.0591). Conclusions: Participating in research interventions requires organizations to understand community barriers to attendance. While transportation is documented as a significant barrier in many studies, this small sample did not show a significant relationship between attendance and travel time using public transit. Further research is needed to examine this barrier with a larger sample, and evaluate other modifiable variables, like perceived benefits and overall satisfaction with study participation, that may increase participation at the BSWHWC.
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    The Impact of the Social Determinants of Health on a Patient with Renal Cell Cancer: A Case Report
    (2023) Luka, Stacy; Hadley, Lesca
    Background Renal cancer is the seventh most common cancer and 90% of cases are renal cell carcinoma (RCC). Symptoms of RCC may include hematuria, abdominal/flank pain, or fatigue, but over half of those with RCC are asymptomatic and diagnosed incidentally by an unrelated abdominal imaging study. Renal tumor size provides the greatest insight into a patient’s chance of survival. For every 1 cm increase in tumor size there is a 16% increase in malignant potential and masses greater than 7 cm have only a 7% chance of being benign. RCC has a 40% mortality rate that disproportionately affects those of low socioeconomic status (SES) who often present with larger and more advanced RCC. This correlation with low SES reflects decreased healthcare access and an increased prevalence of poor prognostic factors including obesity, hypertension, and hyperlipidemia. Additionally, patients without health insurance are 5.6% less likely to survive RCC. Case Information A 56-year-old Hispanic male first presented to a community clinic in Fort Worth, Texas in early 2017 for occasional fatigue and right flank pain that began in 2002. In addition to managing his hypertension, diabetes mellitus, and hyperlipidemia, the physician ordered an abdominal and pelvic CT that revealed a 5.4cm cystic and solid-enhancing right renal mass that was highly suspicious for RCC. Further disease progression was suggested with a 2019 ultrasound showing internal blood flow to the solid component of the mass and 2022 laboratory studies that revealed an elevated BUN (21 mg/dL), serum calcium (10.6 mg/dL), and ALT (56U/L). At the end of 2022, the patient brought in his latest CT report that he could not read because it was only provided in English. The CT revealed the 6.4cm x 4.1cm x 3.7cm mass and while medical translators communicated with the patient, differences in language may have impacted his understanding of his condition. For five years imaging and labs were performed repeatedly to monitor the large tumor, but treatment was never initiated because the patient believed he could not afford care without health insurance. The patient was referred to a local charity program for evaluation, but the program had a policy of not providing cancer treatment. The patient was encouraged to seek treatment in the local county health system, but he believed he could not afford treatment there or the expenses to relocate for treatment elsewhere. At this point, no further options exist for the patient. Conclusions Surgery would provide the greatest odds of survival for this patient, and ideally, it would have been performed before the mass reached such a concerning size. However, the patient believed he could not afford care without health coverage. With such a dismal prognosis, one can only speculate how the outcome would have changed if prompt medical care had been accessible to the patient. His financial resources, health coverage, language barrier, documentation status, and lifestyle all contributed to the unfavorable disease progression. This case serves as a single example of how social determinants of health continue to alter patient outcomes.
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    Influence of Gender on the Association between Race and Disability: California Health Interview Survey
    (2023) Vu, Christine; Nguyen, Uyen-Sa; Peeri, Noah; Quach, Lien
    Purpose: Disability is common in older adults: 40% of those 65 years or older live with a disability in the US. Women typically have higher rates of disability than men in later life. Moreover, minority groups have also been shown to have a higher prevalence of disability than their White counterpart. However, there is very little research regarding the role of gender in the association of race with disability. We aimed to examine whether the association between race and disability differed by men and women. Method: We conducted a cross-sectional analysis using data from the 2015-2016 California Health Interview Survey (CHIS) in adults aged 65 years or older (n=15,044). Due to the complex survey design in CHIS, we accounted for complex sampling weights in all analyses using SAS v9.4. Physical, mental, and emotional disabilities were recorded by participants, and disability was dichotomized as present or absent. Race was classified as Hispanic, Asian, Black, White, and Other. We generated sex- and race-specific descriptive statistics and used multivariable logistic regression to estimate sex-stratified associations between race and disability, adjusting for age, education, marital status, cigarette smoking, arthritis, hypertension, diabetes, mental distress, and walking for work or pleasure. Results: The mean age was 71.5 years for men (range 65-85 years) and 72.2 years for women (range 65-85 years). Participants were predominantly female (59.4%). The majority of participants were White (71.0%) followed by Hispanic (11.4%), Asian (10.7%), Black (4.3%), and other race/ethnicity (2.5%). The prevalence of reported disability was higher among females than males (52% vs. 47%, P=0.0002). The prevalence of disability was highest for Hispanics (60%), followed by Other race/ethnicity (50%), White (48%), Black (48%), and Asian (43%) individuals. Among women, in fully adjusted models, Hispanic individuals were more likely to have reported a disability when compared with white women (OR=1.67, 95% CI= 1.07–2.60). Among males, Hispanic individuals were as likely to have reported a disability as White males (OR=1.03, 95% CI=0.68-1.56). The association between race/ethnicity and disability was not statistically significant for other race/ethnicities. Conclusion: We observed that Hispanic women were more likely to report disability when compared with White women. Further research should be conducted to understand possible factors that contribute to the association between race and disability differently in women than men.
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    Preliminary Results from the DFW Viet-American Health Pilot Study
    (2023) Nguyen, Ngoc; Vu, Christine; Li, Wenjun; Zhang, Yuqing; Spence, Emily E.; Wagner, Russell; Pham, Alena; Tran, Thanh; Franklin, Patricia; Nguyen, Uyen-Sa
    Introduction Arthritis is a chronic condition that can cause pain, physical disability, and reduced quality of life (QOL). The prevalence, severity, symptoms, and management of osteoarthritis (OA) are known to differ by race and ethnicity. Studies on racial differences focused mostly on Black or Hispanic populations with little attention on Asian Americans, such as socioeconomically marginalized, medically under-served, and hard-to-reach Vietnamese-Americans (VietAmericans). This pilot study investigated the occurrence, symptoms, knowledge, and management of arthritis among Viet-Americans. Methods From 7/1/22-8/31/22 and with help from community leaders of faith-based community organizations, we recruited people of Vietnamese descent of age ≥ 45 years and living in the Dallas-Fort Worth (DFW) metroplex.. We translated and adapted a linguistically and culturally appropriate questionnaire from English to Vietnamese using the Translation, Review, Adjudication, Pretesting, and Documentation(TRAPD) Model. Participants completed the survey which asked about their demographics, height, weight, chronic conditions, the 12-item Knee Injury and Osteoarthritis Outcome Survey (KOOS), the Veterans RAND 12-item Health Survey (VR12), and awareness of knee osteoarthritis (OA). We then calculated the body mass index and summary scores for KOOS pain, function, and QOL. Results Of 272 participants who completed the questionnaire (82% enrollment rate), 53% were women and 54% were ≥ 65 years old. The average stay in the US was 30 years (±12.8). The results indicated a low prevalence of overweight (21%) and obesity (6%). Knee OA occurred in 20% of men and 25% of women. Of note, 13% of men and 22% of women said they have rheumatoid arthritis (RA). Only 41% of participants knew that an optimal weight could prevent knee OA. About a third of men and women reported knee pain (KOOS QOL pain score <70). Additionally, 25% of men, 35% of women, and 36% of those ≥65 years reported experiencing pain weekly, daily, or constantly. Furthermore, 40% of men, 53% of women, and 56% of those ≥65 years reported having fair or poor general health. Compared to a year ago, 50% of men and women rated their physical health as slightly or much worse. Although 95% of patients had medical insurance, most of the participants (84%) used alternative pain management such as massages, herbal medicines, and acupressure. Conclusion Participants reported a high prevalence of both OA and RA despite a low prevalence of overweight or obesity. Many people were unaware of risk factors related to OA and how weight management is crucial in the prevention of this disease. The results may be limited by the participants’ knowledge of medical conditions such as OA and RA. The next phase of the study will investigate and examine the reliability and validity of the translated instruments, the accuracy of self-reported OA and RA, and factors associated with poor health, including arthritis-related pain.
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    Association of the Patient-Physician Relationship with Racial Disparities in Chronic Pain Outcomes
    (2023) Pu, Ryan; Licciardone, John C.; Ganta, Sweta; Goehring, Leah; Wallace, Kendall
    Abstract Summary : Purpose: Racial disparities involving health outcomes in the United States have been widely investigated. However, the role of the patient-physician relationship in these disparities remains unclear. Of interest, Black patients may experience different treatment and outcomes relating to pain management. This research aims to determine if the patient-physician relationship mediates the association between race and pain outcomes among patients with chronic low back pain. Methods: Participants in this study were selected from the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION Pain Research Registry) from April 2016 through December 2021. All participants were 21 to 79 years of age, had chronic low back pain according to criteria established by the National Institutes of Health, and had a physician who regularly treated their low back pain. Primary outcomes included low back pain intensity measured with a numerical rating scale and physical function measured with the Roland-Morris Disability Questionnaire. The patient-physician relationship variables were derived from the Communication Behavior Questionnaire, Consultation and Relational Empathy Measure, and Patient Satisfaction Questionnaire. Mediation analyses were performed with the PROCESS v4 software, using multiple mediation models and 95% bootstrap confidence intervals. Results: A total of 1177 participants were studied, including 217 and 960 Black and White participants, respectively. Black participants reported worse outcomes for pain intensity (mean, 7.1; 95% CI, 6.8-7.3 vs. mean, 5.8 95% CI, 5.7-6.0; P< 0.001) and back-related disability (mean, 15.8; 95% CI, 15.1-16.6 vs. mean, 14.1; 95% CI, 13.8-14.5; P< 0.001). The differences in the patient-physician relationship between Black and White participants were not significant, with the exception that Black participants experienced more open and effective communication with their physicians than White participants (mean, 72.1; 95% CI, 68.8-75.4 vs. mean, 67.9; 95% CI, 66.2-69.6; P=0.03). In the mediation analyses, virtually none of the association between race and each outcome was mediated by the individual or combined effects of physician communication, physician empathy, and patient satisfaction. Conclusions: These findings suggest that factors other than the patient-physician relationship are important drivers of pain disparities experienced by Black patients in the United States. Additional research on system factors, such as access to high-quality medical care, may be helpful in identifying more promising approaches to mitigating racial pain disparities.
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    Impacts of Whole School, Whole Community, Whole Child Interventions on K-12 Mental Health
    (2023) Phu, Daniel; Mahasamudram, Prathyusha; Vu, Patrick; Valdez, Alia
    Purpose: Youth mental health is a growing problem, with one third of high school students reporting persistent feelings of sadness or hopelessness in 2019. In 2014, the Association for Supervision and Curriculum Development (ASCD) and Centers for Disease Control and Prevention (CDC) introduced the Whole School, Whole Community, Whole Child (WSCC) model, which emphasizes collaborative networks between educational, community, and health sectors to integrate education, health promotion, and disease prevention. Although the WSCC model has since gained popularity, there remains little data on its impact on K-12 mental health outcomes. This rapid review describes: (1) the current body of research on the WSCC model on mental and behavioral health of students, (2) common practical applications of the model, and (3) future research opportunities. Methods: We conducted a systematic, rapid review of literature on WSCC interventions. Peer-reviewed systematic reviews or primary studies since 2012 that targeted K-12 mental, behavioral, or emotional wellness within the United States were included. A three-person research team reviewed the studies and categorized findings by emerging themes. Results: 460 articles were screened, and 14 were included for review. The results show positive impacts of WSCC interventions on K-12 mental health, particularly: enhancing preventative efforts by facilitating health-education partnerships and strengthening student-educator relationships by incorporating comprehensive wellness into education initiatives. Common challenges include competing priorities and garnering cohesive resources and support for interventions. The professional development of educators and tailoring to high risk groups including LGBTQ students, students of color, and military-connected youth were identified as key components to success. Conclusions: Identifying available evidence and knowledge gaps may inform the implementation of future WSCC initiatives. More discussion and research on its impacts, best use cases, and practical applications are needed, but the WSCC model offers a promising framework for promoting mental and behavioral wellness in the K-12 setting.
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    Craving for Change: Culturally Tailored E-Health Intervention to Support SMART Goal Setting of Lifestyle Modifications Among Underserved Racial/Ethnic Families to Combat Obesity
    (2023) Abed, Fatima; Robinson, Christina; Yockey, Andrew
    Purpose: Examine the impact of the mixed-method intervention program Family Central E-Health, utilizing interactive, culturally tailored, e-health text messaging to promote healthy lifestyle behaviors in six domains (diet, physical activity, sleep, social connection, tobacco cessation, and stress management), and combat chronic disease such as obesity among a diverse racial/ethnic and low socioeconomic sample of caregivers of overweight/obese children. Methods: A sample of 14 adult caregivers of overweight/obese children receiving care from the University of North Texas Health Science Center Pediatric Mobile Clinic participated in the e-health intervention group (n = 8) or a control group of usual care (n = 6). The transtheoretical behavior change framework was applied to health briefs shared through a bi-directional text messaging software to customize SMART (Specific, Measurable, Attainable, Relevant, and Time) goal setting, monitor attitude (motivation and confidence), and assess behavioral change on the six domains of lifestyle modifications. The study aims were accomplished through weekly surveys throughout the study (6-month duration), at study close, 3 months post-intervention, and 6 months post-intervention. Results: Longitudinal analysis and differences in overall means of motivation and confidence between the two groups were minimal and not statistically significant. Descriptive thematic analysis of the participants’ attitudes and experiences revealed lifestyle modification domains of physical activity, social connection, and stress management with the most utilization in SMART goal setting and initiating health-promoting behaviors. Conclusion: The Family Central E-Health intervention may be an effective and culturally sensitive model for managing and preventing obesity, and alike chronic diseases among diverse racial/ethnic and/or low socioeconomic caregivers and their families. Reduction of harmful health behaviors and initiation of health-promoting behaviors through SMART goal setting within the six lifestyle domains can help address existing health disparities. Health education and lifestyle modification interventions are important and future directions include investigating participant empowerment, resiliency, and wellbeing, especially within underserved and diverse communities.
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    Assessing Incontinence Reporting by Women at a Rural Texas Clinic
    (2023) Katz, Hannah; Hadley, Lesca
    Abstract Urinary incontinence is estimated to affect between 20-45% of women in the US; a potential reason that estimates vary is due to underreporting of symptoms. In Eagle Lake, Texas, family physicians are the main source of health education concerning uro-gynecologic issues in women. No local Ob-Gyn or urology specialists practice in Eagle Lake. The two most established family physicians in Eagle Lake are male and they recently discontinued obstetric care. The goal of this project was to assess the prevalence of incontinence and reporting of symptoms by female patients in Eagle Lake, in lieu of a local Ob-Gyn or urologist. The goal of this project was to assess the prevalence of incontinence and reporting of symptoms by female patients in an Eagle Lake Family Medicine clinic, where factors exist which might present barriers to reporting. Methods A paper survey was created the Questionnaire for female Urinary Incontinence Diagnosis was used to screen for incontinence in female patients 55 years and older. Questions concerning willingness to discuss symptoms and use of UI medications were asked in multiple-choice format. Data was collected for 10 weeks, and percentages were calculated in Microsoft Excel. Results Out of 51 total participants, 50.9% screened positive for incontinence and 17.86% take bladder control medications. Out of women with incontinence, 60.71% indicated they have not brought up symptoms to a physician. Out of those who have not brought up symptoms, 13.89% indicated they would not see a physician for bladder symptoms, 13.89% indicated they would see a female physician only, and 69.44% indicated they would see either a female or male physician. Out of women with incontinence who have brought up symptoms with a physician, 27.27% reported symptoms to a female physician, 54.54% have reported symptoms to a male physician, and 18.18% reported symptoms to both a male and a female physician. Conclusions This data demonstrates that more than half of female patients 55 years and older at Rice Medical Associates are incontinent, that more than half of the incontinent women have not discussed their symptoms with a physician, and that less than twenty percent of the incontinent women are on medication for it. Some reasons for underreporting may include insufficient screening in clinic, lack of health literacy on when to seek care, and patient avoidance of discussions concerning "delicate” uro-gynecologic matters. The data shows that some women choose only to discuss bladder symptoms with a female physician, while some choose not to discuss their symptoms at all. Additionally, there were two patients who refused to complete the survey because they were uncomfortable with the topic. Due to research bias from sampling patients in a male family practitioner’s clinic, further studies should survey women outside of a healthcare setting and clarify whether reporting would be different at an Ob-Gyn office. This study indicates the need for purposeful screening for incontinence by rural family physicians, to compensate for underreporting of uro-gynecologic issues by women in areas with limited healthcare options.
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    Prevalence and Factors Associated with SSRI Use Among Adults with Depressive and Thyroid Disorders in the United States
    (2023) Arif, Atiqa; Pinnamraju, Jahnavi; Sambamoorthi, Usha
    Background: Patients with hypothyroidism and hyperthyroidism are at high risk for developing anxiety and depression. Sixty percent of adults in the United States with thyroid disorders have depression. Selective serotonin reuptake inhibitors (SSRIs) are used to treat depression. However, SSRIs reduce thyroid function during treatment suggesting SSRIs may not be used in treating depression among adults with thyroid disorders. Few studies have investigated the prevalence and factors associated with SSRI use in adults with diagnosed depression and thyroid disorders. Objective: This study estimated the prevalence of SSRI use in adults with diagnosed thyroid and depressive disorders in the United States and examined the factors associated with SSRI use. Methods: The study used a cross-sectional design using pooled data from multiple years (2018-2020) of the Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the civilian non-institutionalized population in the US, to gain an adequate sample size. The study was restricted to adults with diagnosed thyroid and depressive disorders with health insurance. The final sample was (Unweighted N=729; Weighted N= 3,090,551). SSRI use was identified from prescription drug files using Multum drug classifications. Rao-Scott Chi-square tests were used to examine the unadjusted group differences in SSRI use. Multivariable logistic regression was used to analyze factors associated with SSRI use. The logistic regressions adjusted for age, sex, race and ethnicity, education, income, insurance coverage, prescription drug coverage, polypharmacy (>6 drug classes excluding antidepressants and thyroid hormones), perceived physical and mental health rating, pain, and thyroid hormones. Results: A majority (61.6%) of adults diagnosed with thyroid and depression used SSRIs. A lower percentage of African Americans (28.5%vs.61.9%; p<.05) used SSRIs compared to NHWs; Only 47.0% of those reporting poor health used SSRI compared to those reporting excellent physical health (73.8%) (p<0.01). A lower percentage of adults with extreme pain (49.5%vs.65.8%) used SSRIs compared to those with mild or no pain (p<.05). A lower percentage of adults with moderate to vigorous physical activity of 5 days/week used SSRIs compared to adults with no exercise. (54.2%vs.65.3%; p<.05). A lower percentage of adults with polypharmacy (53.0%vs.67.5%; p<0.01) used SSRI compared to those without polypharmacy. In multivariable logistic regression, African Americans had lower odds of SSRI use (AOR=0.28; 95% CI=0.09, 0.88) compared to NHWs. Lower ratings of physical health were associated with SSRI use. Adults with polypharmacy had lower odds of SSRI use (AOR=0.65; 95% CI=0.44, 0.96). Conclusion: 6 in 10 adults with thyroid and depressive disorders used SSRIs. Racial disparities in SSRI use were observed. We speculate that SSRI use rates may be lower in those with polypharmacy and poor health to reduce the risk of drug-drug interactions and drug-disease interactions. Strengths and Limitations: Limitations include cross-sectional study design, self-reported data, no distinction between hyperthyroidism and hypothyroidism, and a small sample size despite pooling multiple years. Nevertheless, the study used nationally representative data adjusted for a comprehensive list of clinical, demographic, and psychosocial factors.