United States

Background
Race is a social construct which impacts health outcomes. Race is under-reported in clinical trials making it difficult to identify and address health inequities. In this study, we analyze studies pertaining to cerebrovascular accidents (CVA) with the primary purpose to assess the inclusion of racial data in CVA clinical trials. Our secondary outcome is to assess the racial and gender diversity in CVA clinical trials.

Methods
This meta-analysis consisted of CVA clinical trial data from ClinicalTrials.gov. Two researchers extracted data independently. Microsoft Excel was used for data collection and analysis. The search term “stroke” was used to search clinical trials from 1995-2021. The primary outcome is the prevalence of trials with racial data reported. The secondary outcome is the racial and gender diversity among trial participants.

Results
7004 trials were identified. After excluding non-interventional trials, 468 trials remained of which, 233 studies (49.8%) reported race. The 233 trials with race data totaled 291,876 participants of which 72% were White, 5.05% Black and 19.5% “combined other.” 37.9% were female and 62.0% were male. There were 423,694 participants in 167 trials with pharmacologic intervention, of which 136,847 (32.2%) were female and 286,860 (67.7%) were male. 78 (46.7%) of the 167 trials had race reported resulting in 253,281 (59.8%) participants with race reported. 73.0% of participants were White, 3.76% Black and 19.8% “combined other.”

Conclusions
Of the stroke clinical trials reviewed, only 49.8% reported race. Furthermore, only 46.7% of stroke studies with pharmacologic intervention reported race. Moreover, women and non-White subjects were significantly underrepresented in the stroke clinical trials. The under-representation of women and non-White subjects in these clinical trials raises concern regarding access to stroke clinical trials and the need to further study these disparities.

2022 AMA Research Challenge

Racial Disparities Among Stroke Clinical Trials Between 1995-2021

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Charles Lopresto, DO

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Background:
Digital health technologies have become widely adopted, improving healthcare accessibility and monitoring. However, more clinical trials are needed to establish their standards of care. Clinical trials have historically underrepresented women, older adults, and racial/ethnic minorities; the extent of these inequities in digital health trials remain unknown. Here, we examined gender-, race-, and ethnicity-reporting and enrollment among digital health trials.

Methods:
We searched all trials registered on ClinicalTrials.gov from 2010-2020 that utilized digital health technologies, including medical devices, smartphone applications, computer applications, and telehealth services. Representation of demographic groups was determined by censoring trials that did not report demographic information and comparing enrollment among remaining trials to US population census data; Clopper-Pearson binomial confidence intervals were reported. Prevalence of common chronic conditions were estimated for each ethnicity using the National Center for Health Statistics and compared to representation in trial enrollment. This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

Results:
Of 547 identified US-based trials, 537 (98%) reported gender, 353 (64.5%) reported race, and 252 (46%) reported ethnicity. With respect to the US population, Black individuals (22.9%; 95% CI, 22.5-23.2%) were overrepresented, while Hispanic (16.1%; 95% CI, 15.7-16.5%) and Asian (3.3%; 95% CI, 3.2-3.5%) individuals were underrepresented in digital health trials. Additionally, adults >65 years were overrepresented (18.1%; 95% CI, 9.1-9.8%) while female participants (47%; 95% CI, 46.6-47.3%) and children (9.5%; 95% CI, 9.1-9.8%) were underrepresented. When compared to the share of the prevalence of specific diseases, Hispanic enrollment was low in all measured conditions except for obesity, such as diabetes (20.1% vs 11.4%), hypertension (18.1% vs 7.1%), cancer (15.2% vs 4.7%). 

Conclusion:
Our findings demonstrate the underrepresentation in enrollment of female, Hispanic, and Asian participants in digital health clinical trials. Further efforts to increase the inclusion of these populations in trials evaluating digital health interventions should be considered.


Racial, Ethnic, and Gender Disparities in Digital Health Trial Enrollment from 2010 through 2020

Abstract Title: "Recharge Moments: A Pilot Study Aimed at Recharging the Public Health Workforce"

Background: Recent articles from the CDC and other healthcare agencies have demonstrated the detrimental effects that the COVID-19 pandemic is having on the physical and mental health of the healthcare workforce. Unfortunately, they were less informative in regard to those working for local public health departments. Pre-pandemic and concurrent publications on mindfulness-based interventions have demonstrated the positive and protective effects mindfulness-based interventions can have on burnout prevention and resilience promotion. To gain a better understanding of how the current pandemic might be affecting the public health workforce and to assess whether mindfulness-based interventions would be helpful to this demographic under these current situations, the Recharge Moments program was developed and implemented at a local health department.

Methods: To assess factors of burnout and the mental health status of current employees at Lexington Fayette County Health, a 10-item, Likert scale was developed and proved to be reliable and validated on a random sample population within the health department. To assess the feasibility of implementing the Recharge Moments (short mindful approved employee breaks), a second 10-item, Likert scale was created to assess employee break time tendencies and habits. These two scales were combined with the addition of other questions to create a quasi-experimental pilot study utilizing a pre-and posttest-survey design to measure the effectiveness and utilization of the Recharge Moment program and to gain a better understanding of how the COVID 19 pandemic is affecting the mental and physical health of the employees. Volunteer participants from all departments within the health department who were full-time and currently employed completed the questionnaire: preintervention (n =90), postintervention (n=43). The Recharge Moments program was designed to be a 10-week curriculum, based on weekly emails encouraging mindful breaks while also teaching employees multiple mindfulness-based interventions to utilize during their day to help mitigate work-related stressors.

Results:We noticed encouraging results in the analyses of the pre-and posttest-data on both the qualitative and quantitative assessments. Those that participated in the Recharge Moments program showed improvement in their break time tendencies. They were less likely to utilize their breaks to perform work-related tasks (p=0.05) and less likely to think about/discuss work during their breaks (p=0.0016). The intervention had an effect size of 0.453 with 95% CI [0.085,0.82] on employees' response to "think or discuss work during breaks”. A positive correlation was seen between employees who think about / discuss work during breaks and overall burnout score (r=.30 p=0.04). An increase in program participation correlated with improved break-tie habits (p

Conclusion: The implementation of the Recharge Moment program and encouraging mindfulness-based interventions could help prevent employees from thinking about and discussing work during their breaks. Thus, allowing employees to "recharge" between tasks and lessen many stress-related elements that are contributing to employee burnout. Weekly emails may be a useful reminder to encourage mindful breaks. Workplace leadership and administrative support are encouraged.

Recharge Moments: A Pilot Study Aimed at Recharging the Public Health Workforce

Data chronicling the geo-locations of all 61,589 pharmacies in
the U.S., across 215,836 census block groups were combined with
Medically Underserved Areas (MUAs) information, and the Centers
for Disease Control and Prevention’s Social Vulnerability Index
(CDC-SVI). Geospatial techniques were undertaken to calculate
the distance between the center of each census block and the
nearest pharmacy. We then modeled the expected additional travel
distance if the nearest pharmacy to the center of a census block
closed, and estimated additional travel costs, CO2 emission, and
lost labor productivity costs associated with the additional
travel. Our findings reveal that residents of MUAs have almost
two times greater travel distances to pharmacies, compared to
non-MUAs (4,269 m (2.65 mi) vs. 2,388 m (1.48 mi)), and this
disparity is exaggerated with pharmacy closures (107% increase
in travel distance in MUAs vs. 75% increase in travel distance
in Non-MUAs). Similarly, individuals living in MUAs will
experience significantly greater average annual economic costs
than non-MUAs ($34,834 ± 668 vs. $22,720 ± 326). Our findings
suggest the need for additional regulations to ensure
populations are not disproportionately affected and that there
is a significant through-put with community stakeholders before
any pharmacy decides to close.


Rethinking Access to Care: A Spatio Economic Analysis of the Potential Impact of Pharmacy Closures

Background: Age has a log-linear relationship with COVID-19 mortality, such that increasing age has a higher mortality rate. Senescence of the immune system is hypothesized to contribute to this relationship, while vaccination buffers the effect. The objective of our study was to determine the effect of vaccination and age on COVID-19 mortality in Georgia.
Methods: COVID-19 cases, deaths, and vaccinations were obtained from the Georgia Department of Public Health’s COVID-19 Status Report from February 1st, 2020 to March 23rd, 2022. Arranged temporally, there were three discernible periods of increased mortality rates, corresponding to alpha, delta, and omicron variants for which the area under the curve (AUC1, 2,  and 3 respectively) was calculated to represent cumulative mortality. Superimposing vaccination trends allowed AUC3 to serve as the vaccination time frame. Comparative analyses between cumulative mortality for each age group and wave were conducted, and a chi-squared test compared cumulative deaths among age groups and across AUCs. No significant difference was found between AUC1 and AUC2 (p > 0.025); for the purpose of comparing the non-vaccinated groups to the vaccinated group (AUC3), a weighted average was calculated for AUC1 and AUC2.  
Results: Chi-squared analysis demonstrated a significant association between advanced age and cumulative mortality for the weighted average of AUC1 and AUC2. There was a significant difference between AUC3 and the weighted average (p < 0.01). In AUC3, the greatest mortality burden was among those aged 60-69 years, causing the trend to deviate from a log-linear relationship to a negative skew distribution.
Conclusion: Because AUC3 exhibited a significantly different age-mortality relationship compared to the weighted average, this suggests that vaccination reduces age as a mortality risk factor for COVID-19.  Rather than the log-linear relationship with the greatest mortality burden falling on the eldest population (those aged 80+ years), the mode within the vaccination time period was among 60-69-year-olds suggesting a movement toward age independence when considering mortality from COVID-19.

The Effect of COVID-19 Vaccination in Georgia: Moving Toward an Age-Independent Mortality Paradigm

Background: Vaccine hesitancy is a recognized impediment to reaching a vaccination rate necessary to protect the whole community during the Coronavirus disease 2019 (COVID-19) pandemic, but solutions and interventions to address this issue are limited by a lack of prior research. Thus, the objectives of this study are: (1) to determine if an educational intervention will increase COVID-19 vaccine acceptance and result in more vaccination, (2) to assess the effectiveness of educational interventions regarding COVID-19 virus and vaccines, and (3) to assess attitudes and concerns regarding the COVID-19 virus and vaccines among patients in Michigan.

Methods: Each patient received an initial survey, including questions regarding demographics and knowledge and opinions regarding the COVID-19 virus and vaccines. Then, each patient was randomly assigned an educational intervention in either a video or infographic format. After the intervention, patients received a post-survey to assess changes in knowledge and attitudes. Three-months later, patients received a follow-up survey to assess long-term changes in their knowledge and attitudes. Paired sample t-test were used to measure efficacy of the educational interventions. t-test and analysis of variance were used to measure changes in patients’ attitudes towards the COVID-19 virus and vaccines after the intervention.

Results: Over 230 patients from 18 different Michigan counties were surveyed in this study. Patients’ knowledge increased after the intervention in 6 out of 7 COVID-19 virus and vaccine knowledge (P<0.001, P=0.026, P=0.005, P=0.019, P=0.047, P=0.008). There were significant disparities in COVID-19 vaccine knowledge among different age groups (P=0.05, P=0.045), income groups (P=0.005), and among different political parties (P=0.018). After the intervention, there were statistically significant improvements in the following domains: (1) acceptance of CDC recommendations (P=0.005), (2) trust in the vaccine (P=0.001) and its safety (P=0.019), (3) decreased concern about the mild reactions of the virus (P=0.005), (4) the rapid development of the vaccines (P<0.001), and (5) the vaccine side effects (P=0.031). 

Conclusion: Both video and educational infographics improved COVID-19 virus and vaccine knowledge among patients. Age, income, and political affiliation showed statistically significant differences in COVID-19 knowledge. Gender, race, and age showed statistically significant differences among attitudes towards the COVID-19 virus and vaccines.

The impact of educational interventions in COVID-19 virus and vaccination attitudes among patients in Michigan

BACKGROUND
Hispanic reproductive age women have the second highest fertility rate in the United States in conjunction with higher rates of adolescent and unintended pregnancies. However, little is known about contraceptive choices within this population. Therefore, our study aims to assess the role of birthplace and language preference on contraceptive use.

METHODS
Using the 2017-2019 National Survey of Family Growth, we identified a nationally representative sample of Hispanic women (age 15-49). We compared the risk difference in contraceptive use between Hispanic immigrant Spanish speaking women to other Hispanic immigrant and non-immigrant English-speaking women. We also assessed methods of contraceptives in three categories: permanent, long-acting reversible contraception (LARC), and other less effective methods. 

RESULTS
Among the 1,664 Hispanic women, immigrant Spanish speaking women were 7.7% (95% CI 0.02- 15.3) less likely to use contraceptives than non-immigrant English speaking women. Immigrant Spanish speaking women were 17.7% (95% CI 0.4-35.0) and 19.0% (95% CI 9.0- 30.0) more likely than immigrant and non-immigrant English speaking women respectively to have permanent forms of contraception. Immigrant Spanish speaking women were 14.6% (95% CI 5.5- 23.7) less likely to use lower efficacy methods then non-immigrant English speaking women.

CONCLUSION
Our findings suggest immigrant Spanish speaking women have lower rates of contraceptive use with higher rates of permanent and lower rates of low efficacy contraception use. These findings suggest the potential need for more targeted reproductive and contraceptive education within Hispanic populations.

The Influence of Language and Place of Birth on Use and Method of Contraception Among Reproductive Age Hispanic Women in the United States

Trauma Patient Perspectives on Crime Victim Compensation 
and Post-Discharge Implications

Background
No complete history of black women physicians in the United States exists, and what little mention is made of these women in existing histories is often brief or inaccurate. In my forthcoming book, TWICE AS HARD (Beacon Press, January 2023), I champion a new history, penning the long-erased stories of black women physicians in permanent ink. 

Methods
The primary research method was analysis of oral histories of 19th to 21st century black women physicians, including those that were collected by historians at various institutions like Harvard University and the University of Arkansas. Quantitative data on diversity in medical education and the physician workforce from the Association of American Medical Colleges was used to provide a broader perspective of the experiences of black women physicians. This project utilized an interdisciplinary approach, drawing secondary literature from the fields of African American studies, gender studies, medicine, education, and sociology.

Results
By focusing on the lived experience of black women physicians, some of the barriers that these black women faced, such as discriminatory practices of medical schools and hospitals, were uncovered. Nine (of the 22) physician-based oral histories were emphasized to give a more holistic perspective on individual physician’s lives. The physicians highlighted in the book include Dr. Rebecca Crumpler, the first black woman physician in the U.S., Dr. Edith Irby Jones, the first black person to attend a previously white-only medical school in the Jim Crow South, and Dr. Joycelyn Elders, the first black Surgeon General. The book also shows how the evolution of biomedicine and American society during this 150-year period has influenced these women’s journeys.

Conclusion
While the challenges that black women face to enter medicine has decreased over time, significant barriers persist. This is evident in their overall underrepresentation in medicine; black women make up less than 3% of physicians nationally. Medical institutions can help to reduce this underrepresentation through mentorship, advocacy, and support for the black women along this path. These strategies can also be expanded to other underrepresented minorities in medicine who share similar challenges with black women in medicine.

TWICE AS HARD: The Stories of Black Women Who Fought to Become Physicians from the Civil War to the 21st Century

Wastewater surveillance of SARS-CoV-2 has shown to be a valuable source of information regarding SARS-CoV-2 transmission and COVID-19 cases. Though the method has been used for several decades to track other infectious diseases, there has not been a comprehensive review outlining all of the pathogens surveilled through wastewater. The aim of this study is to identify what infectious diseases have been previously studied via wastewater surveillance prior to the COVID-19 Pandemic and identify common characteristics between the studies, as well as identify current gaps in knowledge.

Wastewater Surveillance for Infectious Diseases: A Systematic Review

Background
The COVID-19 pandemic has illuminated the United States (US) healthcare system’s lack of preparedness and put healthcare communities (HCs) at increased risk for adverse outcomes (e.g., discrimination and racism via microaggressions, hate crimes, or even death). In this study, we investigated 1) prevalence of discrimination; 2) the risk of microaggressions and hate crimes (MAHCs) experienced by healthcare workers (HCWSs); 3) which specific subpopulations were affected; 4) the driving factors of these attitudes and actions; and 5) perceived fear of COVID-related complications (e.g., infectivity, illness, death, and etc.).

Methods
A cross-sectional survey was disseminated to US HCs, incorporating the validated Everyday Discrimination Scale and assessing risk and driving factors behind MAHCs. Logistic regression was used to estimate risk of MAHCs among HCWSs before and during the pandemic.

Results
1218 participants were included, with 230 (19%) reporting an increase in everyday discrimination. Most common types of discrimination reported were verbal harassment (42%) and physical assault (25%) with suspected reasons for experiencing and witnessing MAHCs being race (16%), ethnicity (20%), and gender biases (18%). Furthermore, physicians [OR: 1.46 (95% CI: 1.07-1.99)], students [OR: 1.81 (95% CI: 1.03-3.17)], and other medical professionals [OR: 1.30 (95% CI: 0.96-1.77)] had higher risks of ever experiencing a MAHC compared to nurses after adjusting for gender, race, ethnicity, and age. Perceived risk and fear regarding COVID-19 infections were high for Asian/South Asian/Southeast Asian and Native Hawaiian/Pacific Islander HCWSs. Lastly, 19% of participants reported purchasing or knowing someone who purchased a firearm due to COVID-19 related safety concerns. 

Conclusion
COVID-19 has unmasked systemic maladies, especially for HCWSs, who possess a complex duality of roles as healers and potential carriers of disease and illness. More studies are needed to capture xenophobic and racist occurrences which are often overlooked and undocumented. These studies are imperative to inform the development of prevention and intervention programs that will combat systemic injustices and safeguard HCWSs from adverse outcomes.

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Racial Disparities Among Stroke Clinical Trials Between 1995-2021

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