United States

Background: Telehealth has the potential to increase healthcare access for people who use drugs (PWUD), a typically medically underserved population, by overcoming geographical and temporal barriers. However, PWUD’s access to telehealth and necessary technological infrastructure, such as the internet and computers, remains understudied. We studied the access to digital technology and telehealth utilization among PWUD to inform the planning of telehealth interventions tailored to their needs.
Methods: We employed respondent-driven sampling to recruit 162 PWUD to participate in a 109-item structured questionnaire. Eligibility criteria required participants to be at least 18 years old, have a history of injection drug use (IDU), and Greek verbal fluency. The main study outcomes included current internet and computer access, and telehealth use. We used logistic regression to evaluate the impact of sociodemographic characteristics and IDU on these outcomes.
Results: The participants&#39; mean (standard deviation) age was 45.9 (8.8) years, with 84.0% (136/162) being male and 90.1% (146/162) Greek. Among the participants, 77.8% (126/162) reported IDU within the past year, 85.2% (138/162) were not currently linked to opioid agonist treatment, and 50.0% (81/162) were currently experiencing homelessness. Internet and computer access were reported by 66.0% (107/162) and 31.5% (51/162) of participants, respectively. Compared to participants with secure housing, those currently experiencing homelessness reported decreased internet (50.6% vs 81.5%, p&lt;0.001) and computer access (11.1% vs 51.9%, p&lt;0.001). Only 1.9% (3/162) had ever used telemedicine, and 24.1% (39/162) reported awareness of telemedicine as a healthcare delivery modality. Multivariable analyses revealed that increasing age (per 1-year increase: odds ratio [OR]=0.94, 95% confidence interval [CI], [0.89, 0.99], p=0.03), IDU within the past year (0.29 [0.10, 0.88], p=0.03), and homelessness (0.29 [0.13, 0.65], p=0.003) were associated with lower odds of internet access. Unemployment (0.25 [0.07, 0.98], p=0.05) was also associated with lower odds of computer access.
Conclusion: Homelessness, older age, unemployment, and IDU within the past year were associated with limited access to digital technology among PWUD. These factors, along with the need to enhance patient education on telehealth, should be considered in policy development to ensure equitable access to digital healthcare for underserved populations.


AMA Research Challenge 2024 

Exploring digital healthcare access among people who use drugs

Background: Telehealth has the potential to increase healthcare access for people who use drugs (PWUD), a typically medically underserved population, by overcoming geographical and temporal barriers. However, PWUD’s access to telehealth and necessary technological infrastructure, such as the internet and computers, remains understudied. We studied the access to digital technology and telehealth utilization among PWUD to inform the planning of telehealth interventions tailored to their needs.
Methods: We employed respondent-driven sampling to recruit 162 PWUD to participate in a 109-item structured questionnaire. Eligibility criteria required participants to be at least 18 years old, have a history of injection drug use (IDU), and Greek verbal fluency. The main study outcomes included current internet and computer access, and telehealth use. We used logistic regression to evaluate the impact of sociodemographic characteristics and IDU on these outcomes.
Results: The participants' mean (standard deviation) age was 45.9 (8.8) years, with 84.0% (136/162) being male and 90.1% (146/162) Greek. Among the participants, 77.8% (126/162) reported IDU within the past year, 85.2% (138/162) were not currently linked to opioid agonist treatment, and 50.0% (81/162) were currently experiencing homelessness. Internet and computer access were reported by 66.0% (107/162) and 31.5% (51/162) of participants, respectively. Compared to participants with secure housing, those currently experiencing homelessness reported decreased internet (50.6% vs 81.5%, p<0.001) and computer access (11.1% vs 51.9%, p<0.001). Only 1.9% (3/162) had ever used telemedicine, and 24.1% (39/162) reported awareness of telemedicine as a healthcare delivery modality. Multivariable analyses revealed that increasing age (per 1-year increase: odds ratio [OR]=0.94, 95% confidence interval [CI], [0.89, 0.99], p=0.03), IDU within the past year (0.29 [0.10, 0.88], p=0.03), and homelessness (0.29 [0.13, 0.65], p=0.003) were associated with lower odds of internet access. Unemployment (0.25 [0.07, 0.98], p=0.05) was also associated with lower odds of computer access.
Conclusion: Homelessness, older age, unemployment, and IDU within the past year were associated with limited access to digital technology among PWUD. These factors, along with the need to enhance patient education on telehealth, should be considered in policy development to ensure equitable access to digital healthcare for underserved populations.

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Purpose: In California, nearly half of all adults have prediabetes or diabetes. In Fresno County, an even higher percentage is present in minority communities. Due to the lack of research on the culturally specific and socioeconomic barriers to care for these patients, this study focused on furthering research in these regards at United Healthcare Center Fowler, a community healthcare center in Fowler, CA.
Methods: A mixed-methods approach to identify barriers to care in Fowler, featuring both surveys and interviews. Surveys were based on the Diabetes Self-Management Questionnaire-Revised (DSMQ-R) and self-reported barriers the patients were facing. Surveys were offered in English and Spanish. Barriers listed included diet, knowledge regarding diabetes management, and issues related to doctor's appointments, among others. Interviews were conducted voluntarily and limited to those with HbA1c levels greater than 5.7%. They focused on three topics: a personal story related to their life with diabetes, their self-management of diabetes, and their biggest struggle to self-manage diabetes.
Results: The most notable barriers to the management of diabetes in Fowler were lack of access to affordable, healthy dietary options and maintaining a diet that was both healthy and culturally specific, both of which greater than 50% of patients reported as barriers.
Conclusion: By identifying that barriers to dietary options are a vital barrier in managing diabetes in the Fowler community, we can anticipate future interventions to ease this burden, including CalFresh pamphlets regarding healthy food options, as well as patient-specific nutritional counseling that factor in the cultural aspects of their diets.

Identifying Barriers to Diabetes Management Among Patients at UHC Fowler

Background
The American Cancer Society (ACS) is a national non-profit that aims to eliminate cancer via research and lobbying, the latter of which is done through the Cancer Action Network (ACS CAN). ACS CAN hosts Cancer Action Days for survivors and other people involved with ACS to lobby at their state government offices. The bills lobbied for this year were on access to lung cancer screening, creating an adult vaccination record, and protecting genetic information from insurance calculation. It would be important to know if the process of lobbying increases the lobbyists’ agreement with the bills. 

Methods
A questionnaire was drafted using the yearly questions associated with Cancer Action Day that captured demographic data as well as bill opinions graded by 7 point Likert score. The questionnaire was duplicated into a pre- and post- survey with conglomerate data collection. The surveys were administered at the New York State Capitol on 5/7/24. 

Results
42 respondents filled out the pre-survey, 30 respondents filled out the post-survey, and of these there were 20 people who filled out both surveys allowing us to compare these groups. The people who were at Cancer Action Day were cancer survivors (those who completed cancer treatment, 37%), cancer thrivers (those undergoing treatment, 6%), caregivers (those who take care of people with cancer, 20%), lobbyists (11%), and other (26%). Ninety six percent of attendees knew someone with cancer, including themselves (46%), a family member (21%), a work colleague (4%), and more than one person (25%). Most people who attended Cancer Action Day were in the age range of 55-65 (31%), followed by 45-55 (24%), with the median age of participants being in the range of 45-55. The average Likert score of satisfaction on access to lung cancer screening increased from 3 to 4 in pre to post survey (T-test unequal variances, 0.064>0.05). The average Likert score of agreement on increasing vaccinations for adult cancers remained at 6 (0.262>0.05). The average Likert score of agreement on protecting genetic information decreased from 7 to 6(0.274>0.05).

Conclusion
The increased Likert score for lung cancer, and the decrease for genetic information may indicate that through lobbying individuals learn more about the disparities in access to these levels or care. In conclusion, the ACS CAN lobbying changes people’s opinions on current political issues in cancer without statistical significance. For future research, it would be important to expand the sample size of the study by incorporating multiple lobbying events.

Impact of Lobbying Efforts of the American Cancer Society at New York Cancer Action Day

Background
The National Institute of Drug Abuse (NIDA) asserts that effective treatment for substance use disorder (SUD) must address a diverse range of individual needs. Recovery-oriented systems of care (ROSC) have been established to respond to the long-term needs of individuals with SUD. Their mechanism of change includes community-based networks that prevent, intervene in, and treat SUD. In Illinois, ROSC networks include a diverse range of stakeholders at the county level (i.e., healthcare providers, law enforcement, local businesses, and individuals with a history of substance use) who work together to build effective care coordination systems. Understanding how members view their network’s effectiveness is important in determining their utility in the coordination of SUD treatment and prevention. The objective of this study is to assess the capacity of ROSC networks to improve care coordination and Narcan (naloxone) distribution. 

Methods
ROSC council members in the state of Illinois were identified using publicly available membership rosters and contacted via email with a link to an anonymous survey focused on the participant's involvement with their ROSC council and their perception of its quality and effectiveness (n=61). 

Results
ROSC networks were composed of stakeholders representing recovery programs (30%), social services (28%), substance treatment (25%), and behavioral health (25%) among others. Members participated in their ROSC network for an average of 23 months (16.9) and most attended more than 10 meetings (58.3%). Over half of respondents believed the network improved care coordination to a very great extent (48.8%) or to a great extent (26.8%). A little over half also believed the network improved Narcan distribution by a great or very great extent (51.2%). Perception of better care coordination was associated with better perception of Narcan distribution (X2(15)=29.39, p<.01).

Conclusion
The majority of respondents, representing a diverse range of stakeholders, indicated that ROSC networks improve care coordination and Narcan distribution. There is a statistically significant positive relationship between perceived care coordination and Narcan distribution, suggesting that improved care coordination between community stakeholders through ROSC networks may improve Narcan distribution. ROSC networks are perceived to be effective in coordinating SUD care by those who work within them and therefore may be an effective model to improve SUD treatment and prevention within communities.

Impact of Recovery-Oriented Systems of Care on Substance Use Disorder Coordination and Narcan Distribution in Illinois

Objective: Idiopathic inflammatory myopathies (IIMs) have heterogeneous presentations and require multiple lines of testing, some of which are invasive, to diagnose. Additionally, treatment is chronic and can be costly. Delays in diagnosis are known to occur and can lead to significant morbidity. This study aims to investigate the influence of socioeconomic status (SES) on time to diagnosis, treatment, and improvement in disease status of IIMs. 

Methods: This is a retrospective study patients from 2011-2021 from a university hospital and a county safety-net hospital. Salient clinicopathologic and demographic data including race, ethnicity, sex, zip code, median household income, and insurance data were abstracted. Patients with ICD codes for polymyositis, dermatomyositis, inclusion body myositis, other inflammatory or immune-mediated myositis were included. The modeling of time-to-event and binary outcomes incorporated covariates such as median household income, race, ethnicity, sex, insurance status (Charity vs. Medicare/Medicaid vs. Other), and inpatient status (Inpatient = 1, Outpatient = 0). Time-to-event data were analyzed using Cox proportional hazards models through the survival package in R.

Results: Our study included 2,258 subjects, of which 1,734 were from the academic hospital and 524 were from the safety-net hospital. After filtering for patients with the proper diagnosis, there were 46 from the academic and 143 from the safety-net hospital. There is no significant difference in time from first abnormal muscle enzyme level (creatine kinase, CK) to diagnosis between race, median household income, ethnicity, and initial presentation in the inpatient vs. outpatient setting. However, those receiving charity had a 4.58-fold increase in the instantaneous probability of being diagnosed after first positive CK after 230 days (p = 0.009). Those on Medicare/Medicaid had a 62% decrease in the instantaneous probability of being diagnosed after first positive CK within the first 94 days (p = 0.02) but a 4.60-fold increase in the instantaneous probability of being diagnosed after first positive CK after 230 days (p = 0.006). There is no significant difference in the probability of a muscle biopsy being order or the time to disease improvement between races, ethnicities, sexes, income, or insurance status.

Conclusions: Our findings showed that there could be delays in diagnosis for those with Medicare/Medicaid or those receiving charity to finance their care. There was no impact detected from race, ethnicities, or sexes. While income did not clearly correlate with insurance status, income is limited by zip-code level data rather than individual data. Our study sheds light on populations that may have delays in diagnosis and treatment, which could lead to increased disease morbidity. Unfortunately, increased morbidity in the population identified will only perpetuate the cycle of poverty and add greater burden to the healthcare system. Future studies will seek to examine impact of SES and disease outcomes.


Impact of socioeconomic factors on time to myositis diagnosis and treatment


Background
Universal helmeting has been shown to decrease fatalities associated with motorcycle accidents, and helmeting may reduce the incidence of traumatic brain injury, facial fractures, and injury severity for the head and neck. Enhancing rider knowledge of safe riding practices and effective helmeting are approaches that may improve motorcycle safety.

Methods
The dissemination of a motorcycle safety toolkit in areas frequented by riders, or in proximity to vulnerable populations could provide a means for teaching about educational offerings and safety resources. Our team utilized the graphic design platform Canva to create a concise handout highlighting New Jersey helmeting laws, tiers of helmet safety, and crash statistics, among other topics. We utilized quick-response (QR) codes so viewers can interact with the toolkit from their phones. Leaders in roadway safety from across New Jersey were consulted in developing these resources. Collaborators included rider safety educators, injury prevention professionals, and authorities in public safety and policy.

Results
Strong positive feedback was received by the New Jersey Trauma Injury Prevention Council. Several organizations stated they plan to use the toolkit in their community outreach efforts, including:

· New Jersey's Governor's Office
· New Jersey Division of Highway Traffic Safety
· New Jersey Brain Injury Alliance Motorcycle Safety Committee
· AAA - New Jersey Division
· Monmouth and Ocean Traffic Safety Officers Committee.

The toolkit has been received favorably by a cohort of patients hospitalized with motorcycle-related injuries. These individuals received the toolkit together with motivational interviewing emphasizing safe riding.

Conclusion
Efforts may be made to share the toolkit in a variety of settings and to better understand factors contributing to motorcycle-related injury. Our collaborators can broaden the reach of the toolkit, incorporating it into safety courses, sharing it on social media, or using it to guide conversation with survivors. We can track use of the toolkit through analytical tools measuring viewership. A retrospective cohort study investigating the relationship between helmeting and injury severity scores and health outcomes among victims of motor-vehicle collisions locally could identify areas of focus for further education. It remains to be seen where this toolkit will reach the most motorcyclists and whether education is a limiting factor in the prevention of motorcycle-related injury and fatality. A better understanding of the financial and social factors that complicate the use of safe and effective helmets is imperative in reducing fatalities.

Implementing a Motorcycle Safety Toolkit: A Resource for Riders and Providers

Background
Medical Students Making Change (MSMC), led by University of South Carolina School of Medicine Columbia students in collaboration with The Free Medical Clinic in Columbia, SC, aims to improve diabetic control in South Carolina. Approximately 13.2% of South Carolina’s adult population has diabetes. With serious complications such as heart disease, stroke, and amputation, diabetes costs South Carolina an estimated $5.9 billion each year. By pairing medical student volunteers with diabetic patients for routine check-ins, MSMC seeks to strengthen patient understanding of their health and lifestyle trends with the goal of improving patient glycemic control as measured by A1C levels. A new recruitment method was implemented where medical student volunteers went to The Free Medical Clinic weekly to participate in A1C screening and patient recruitment aiming to increase MSMC patient enrollment and A1C screening capabilities.
Methods
MSMC implemented a weekly A1C screening and enrollment clinic starting in January 2024. During this session, medical student volunteers reviewed A1Cs from the previous week, contacted eligible patients, screened eligible patients in the clinic, and attempted to enroll those meeting the inclusion criteria: adults (≥18 years old), diagnosed type 2 diabetes, access to a phone, and an A1C ≥6.5%. MSMC volunteers screen patients for diabetes using A1C test kits. The Free Clinic providers provide MSMC with patients current BMI and glucose to assist with goals. Patients are then paired with a trained medical student volunteer and provided educational materials regarding T2DM management. Phone calls between volunteers and
patients focus on assessing goals related to diet, exercise, sleep, and hydration. Volunteers address barriers to achieving goals and navigate solutions. HbA1C and fasting blood glucose are measured every 3 months to monitor glycemic control.
Results
Fourteen patients were enrolled in the MSMC program between January-April 2024. The average BMI was 38.7. The average base A1C was 9.6%, and the average fasting blood glucose was 246. Of the patients enrolled in the MSMC program with 3-month A1C values, there has been an average decrease in A1C of 1.7%.
Conclusion
The clinic’s high A1C average highlights a need for lifestyle and therapeutic interventions within this demographic. This preliminary data further emphasizes the need for patient education and intervention to improve glycemic control and thereby attenuate the complications associated with insulin resistance/type 2 diabetes.

Improving Diabetic Patient Enrollment & A1C Screening Capabilities at South Carolina Free Clinics: A 6-month progress update

Background:
Addressing health disparities in U.S. border states requires overcoming linguistic barriers that disproportionately affect the Hispanic/Latino population. This review critically evaluates the potential of Medical Spanish Certification (MSC) in medical school curricula as a strategy to advance health equity by improving communication between healthcare providers and patients with Limited English Proficiency (LEP).

Methods:
This review was conducted by systematically searching PubMed, Scopus, and Embase databases for literature published up to 2023. The search focused on studies, policy documents, and educational materials related to MSC, language concordance in healthcare, and the feasibility of MSC implementation in medical education. Selection criteria were established to include articles that directly address the debate on MSC in border states, its implications for healthcare delivery, and educational challenges. The review concentrated on analyzing arguments for and against MSC, evaluating evidence on the benefits of language concordance, and identifying barriers to MSC program implementation. Quality assessment and thematic analysis were performed to ensure a balanced evaluation of the available evidence.

Results:
Evidence highlights that language concordance through MSC significantly enhances patient care outcomes, satisfaction, and access. Proponents argue MSC bridges communication gaps, potentially reducing medical errors and improving care engagement. The growing demand for Medical Spanish courses mirrors the urgent need for bilingual healthcare skills amid demographic shifts. However, challenges such as curriculum constraints, resource allocation, and the potential for ethical dilemmas and tokenism raise concerns about mandating MSC. While the demand for Medical Spanish courses is rising among medical schools, there is variability in program implementation and a lack of standardized assessment methods.

Conclusion:
Incorporating MSC into medical curricula presents a nuanced approach to mitigating healthcare disparities and advancing health equity in border states. A voluntary certification model, supplemented by adequate resources and a focus on cultural competency, offers a practical solution. Standardizing MSC education and conducting further research are essential steps toward leveraging language concordance as a means to enhance health equity for the Spanish-speaking LEP population.

Navigating Linguistic Barriers: The Debate on Medical Spanish Certification in Border States

Background. Vaccine hesitancy hinders the eradication of preventable illnesses. Furthermore, there are gaps in public health research on vaccine hesitancy among Muslims in heterogenous societies.
Methods. Participants were recruited through Facebook group posts. Seventy-three responses were received. Sixty-three responses met the inclusion criteria and were included in the final analysis. Participants rated their opinions on political beliefs, religious practices, trust in institutions and vaccines. Answers were compiled into the following belief scores: political leaning, religiosity, trust in public institutions, and vaccine hesitancy.
Results. From bivariate analysis, participants who were older in age, attained higher levels of education, were employed, were not married, and identified with the Sunni sect were less vaccine hesitant. From multiple regression analysis, participants with higher education levels and trust in public institutions were the least likely to express vaccine hesitancy. No belief score had a significant correlation with vaccine hesitancy. Most participants (36.5%) were more likely to receive a vaccine it had no potential safety issues. Moreover, they were hesitant with vaccines if they had safety concerns or had poor efficacy.
Conclusion. Results both align with and contradict previous studies in Muslim majority and religiously heterogenous countries. This study is the first of its kind to find an association between Islamic sect and proclivity towards vaccines. Follow up studies are necessary to gauge a larger, more diverse population of Muslim-Americans. Based on this study’s findings, healthcare professionals can better promote vaccines by addressing their patient’s trust in public institutions.

Prevalence and beliefs associated with vaccine hesitancy among Muslim-Americans

Background
Women Veterans are one of the fastest growing groups of new VA users and are younger and more racially diverse than their male counterparts. Yet services such as obstetric care continue to be purchased from the community due to concerns regarding capacity and quality given the limited demand at any one VA site. Understanding whether or not racial and ethnic disparities in reproductive health care and outcomes are evident among women Veterans is critical for ensuring that VA meets its goal of providing high quality, equitable care to all Veterans. The purpose of this scoping review was to examine the evidence with respective to racial and ethnic disparities in reproductive health care and outcomes among women Veterans.

Methods
Databases were queried for articles addressing reproductive health and health care of women Veterans between 2008 and 2023, pertinent to reproductive health care or outcomes of women Veterans that also included outcome frequencies by race or ethnicity or measures of association for race or ethnicity with the outcome of interest. Articles were sorted into six categories based on topic: contraception, infertility, pregnancy, reproductive health screenings, gynecology, menopause. Outcomes were defined as structural, process, or clinical or behavioral outcome measures.

Results
Of 438 original articles, 49 articles were included. The topics with the greatest number of articles included pregnancy (43%) and contraception (24%). In terms of types of measures, only two studies included at least one structural measure (7%) and the remainder were split nearly evenly between process measures (53%) and clinical and behavioral outcomes (57%, n=28). In nearly two thirds of the studies racial and ethnic disparities were not the primary focus of the analysis and were reported only as secondary outcomes. In terms of process measures for pregnancy, non-White Veterans were less likely than White Veterans to return to VA primary
care postpartum, but results were mixed for other measures. With respect to clinical and behavioral measures, although Black versus White Veterans were consistently found to be more likely to have a low birthweight baby, results were variable regarding preterm birth, breast feeding, prenatal smoking, and perinatal mental health.

Conclusion
This scoping review identified numerous racial and ethnic disparities in reproductive health care and outcomes among women Veterans. These findings suggest a need to ensure that Veterans receive culturally competent, patient-centered contraceptive counseling and a need to potentially address social determinants in the context of reproductive health care.

Racial and Ethnic Disparities in Reproductive Health Care Among Female Veterans:
A Scoping Review

Introduction: Equitable inclusion and representation of racial/ethnic groups in clinical trials is important in producing generalizable data. Disparities and mismatches between clinical trial participants trials’ enrollees and general population result in selection bias and distortion of information generated by these studies. The purpose of current study was to investigate the status of racial/ethnic disparities in the ophthalmology clinical trials conducted in the United States. 
Methods: In this retrospective cross-sectional study, we utilized demographic reports of completed phases 2/3, 3, and 4 ophthalmology clinical trials conducted in the US, using the ClincialTrials.gov database. We calculated proportional enrollments of racial/ethnic groups in the trials and compared them to the 2010 US Census data as the reference population. Using regression analysis, we examined the association between various trial features (i.e., phase of the trial, starting year, funding source, and primary condition) and rate of disclosing demographics data and inclusion of racial/ethnic minorities.
Results: Among the total of 653 completed trials, racial/ethnic background were reported in 128 trials (43.6% of the studies, comprising 3 7031 participants). Compared to the US census data, White individuals were enrolled more commonly (median 76.6%, Inter quartile range (IQR) 69.0-84.0%) and minority groups, including Asians (median 1.8%, IQR 0.4-3.8%), Hispanics (median 12.5%, IQR 6.3-17.5%), and other group (median 1.7%, IQR 0.2-4.3%) were underrepresented (p<.001). Interestingly, enrollment of African-American individuals was comparable to their population estimates (median 12.4%, IQR 6.2-20.8, p=0.44). Rate of reporting race/ethnicity data was higher among earlier phase (2/3 and 3) trials and increased over time (average increase of 11.4% annually; p<0.001). Additionally, glaucoma trials had greater enrollment of Black individuals (p=0.001). 
Conclusion: Racial/ethnic disparities in clinical trials enrollment can skew the results of these studies and compromise generalizability of findings. Ophthalmology trials suffer from significant underrepresentation of minorities. More efforts are needed to reduce disparities and ensure unbiased discoveries.

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