United States

Introduction
Despite the preventable nature of oral and oropharyngeal squamous cell carcinoma (OOPSCC) through risk factor avoidance, disparities persist regarding OOPSCC survival in medically underserved communities. This qualitative study aims to engage community stakeholders from a medically underserved neighborhood in Miami, FL to identify key problems and solutions related to high-risk behaviors associated with OOPSCC.

Methods
Twelve participants, selected based on community involvement and residence around the studied neighborhood, participated in two focus groups with six participants each. Transcriptions of the 60-minute sessions were analyzed using directed qualitative content analysis (DQICA) to identify common themes. Notable excerpts from the transcriptions were used to report the data and support overarching themes.

Results
12 participants of average age 45.6 years were extensively interviewed. The majority were female (75.0%), had 0-1 years community involvement (83.3%), were Black or African American (100%), and were non-Hispanic (83.3%). DQICA revealed five key problems contributing to high-risk behaviors for OOPSCC: historic social norms, mistrust of the healthcare system, lack of support systems, limited education, and availability of drugs and alcohol. Analysis identified five key solutions including continuity of care, community engagement and education, incentives, long-term relationships, and improved health accessibility.

Conclusions
This study highlights the influence of social determinants on OOPSCC risk in this medically underserved community of Miami, FL. Through a community-engaged approach, this study uncovers underlying problems and potential solutions to reduce high-risk behaviors contributing to OOPSCC. Addressing these factors is crucial in combating socioeconomic and racial disparities and improving overall OOPSCC survival.



AMA Research Challenge 2023

A Community-Engaged Approach to Uncovering High-Risk Behaviors for Oral and Oropharyngeal Cancer

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Background:
Policymakers have promoted Urgent Care (UC) as an alternative to the emergency department. We examined the proportion of UC visits managed by emergency physicians (EPs) vs other providers and how this distribution has changed over time.

Methods:
We examined UC claims for a national, 20% sample of Medicare beneficiaries age 65 and older from 2011-2017. We identified provider specialty, patient characteristics and visit diagnosis. For each year, we calculated the number of UC visits per 100 beneficiaries as well the rate and proportion of visits managed by provider specialty. We then created 3 specialty groups: EPs, advanced practice professionals (APPs; nurse practitioners, physician assistants) and other physicians. We compared visit characteristics among these groups for 2016-2017.

Results:
In our sample of 2,517, 333 UC visits, utilization rose from 3.8 UC visits per 100 beneficiaries in 2011 to 9.3 visits per 100 beneficiaries in 2017. The most frequent provider specialties were family practice (FP), emergency medicine (EM), physician assistant (PA), nurse practitioner (NP) and internal medicine (IM). All 5 specialties saw a rise in utilization, but the relative increase was greatest for NPs (+603%), followed by PAs (+337%), IM (+104%), FP (+81%), and EM (64%). FP, the most frequent specialty, declined from 39.9% of visits in 2011 to 30.0% in 2017. EPs were the second most common providers in 2011 (25.8%) but dropped to fourth place in 2017 (17.6%). Visits to PAs rose from 13.7% to 22.6% and NPs from 6.4% to 18.6%. The top diagnoses were upper respiratory tract infection (14.6%), urinary tract infection (6.2%), bronchitis (6.0%), skin infections (4.6%) and lower respiratory tract infection (4.3%) and this distribution was stable over time. EPs cared for older patients (mean 75.4 years) compared to APPs (74.8 years) and other physicians (75.2 years). Chronic condition burden was lowest for APPs, followed by EPs and other physicians. Non-EM physicians cared for the greatest proportion of Medicaid-eligible beneficiaries (7.9%) followed by APPs (6.8%) and EPs (6.0%).

Conclusions:
UC utilization has risen markedly in recent years but this rise has been greatest for APPs, with a decline in the proportion of visits managed by EPs and other physicians. EPs cared for an older, sicker population while FPs saw a greater share of disadvantaged patients as measured by dual Medicaid-eligibility. 


Trends in Provider Specialty for Urgent Care Visits Among Medicare Beneficiaries from 2011-2017

Background:
Non-Government Organizations (NGOs) promote social and political change by implementing programs focusing on health, emergencies, advocacy, education, and supporting communities. Without these programs, the World Health Organization reports critical healthcare shortages in regions like Sub-Saharan Africa, where only about 2.3 healthcare workers are available per 1000 population. These programs, however, prove futile without the ability to effectively hand them off to local ministries for long-term and quality maintenance. 

Methods:
A keyword Google Scholar literature search was then completed using terms such as NGO, handover, changing needs, adaptation, decline, deterioration, community, impact, training, and sustainability. Once articles were identified, a PICO Evidence-Based Framework was used to compare successful and unsuccessful handoffs of International Medical NGO programs to regional Ministries of Health in Sub Saharan populations based on their transition readiness. 

Results:
Major factors shown to impact a handoff's success include effective collaboration with Ministries of Health, timing of the handoff, an appropriate account of resources (i.e. staff and equipment), and the clear organization and allocation of these resources before and during the transition.

Conclusion:
Our findings indicate that emphasis should be placed on advanced planning, where the stability and longevity of these programs after handoff are more likely to be successful when they are well funded, establish clearly defined roles and responsibilities, and anticipate limitations based on the regions they plan to serve.

"A Literature Review Exploring Successful vs. Unsuccessful Handoffs from NGOs to Ministries of Health in Sub-Saharan Populations"

Background
Studies have shown that food-insecure households are two to three times more likely to develop diabetes. The increasing prevalence of diabetes has resulted in significant costs in both government healthcare spending and annual costs for diabetic patients. Additionally, food insecurity among diabetic patients has been shown to contribute to the progression of diabetes and the development of complications like chronic kidney disease, which worsen health outcomes and result in billions more in annual healthcare spending.
Uninsured diabetic patients face additional significant barriers to care and have limited access to primary care services, which can result in poor glycemic control and subsequent advanced disease and comorbidities. As a result, this patient population often relies on safety net programs like Federally Qualified Health Centers and emergency department visits to receive care. However, the use of emergency department services has contributed to rising annual healthcare costs and poses a significant strain on emergency departments, especially in the communities that serve them.

Case Presentation
Increasing the geographical density of FQHCs has been found to reduce emergency department visits among uninsured patients, may reduce uncompensated costs incurred by uninsured diabetics, and provide a pathway for earlier intervention. Some additional strategies to mitigate the prevalence of diabetes have been the implementation of Community Health Workers (CHWs), which has been shown to be a cost-effective strategy to improve diabetes management and reduce emergency room visits. More recently, there have been several initiatives by the White House and USDA to mitigate food insecurity through "food as medicine" prescription programs. Though these various strategies and resources have been shown to reduce costs and improve patient outcomes, siloed efforts, the temporary nature of these programs, and lack of sustainability have been cited as barriers.

Discussion
Therefore, I propose an increase in the geographical density of Federally Qualified Health Centers, increased implementation of community health workers, and expansion of existing federal nutrition assistance grant programs to address the prevalence of diabetes and food insecurity. Additionally, implementing on-site food pantries would be especially important in FQHCs that serve uninsured patients who face significant barriers to transportation and may not qualify for federal programs like SNAP. These strategies can not only improve health outcomes but may reduce overall healthcare spending on diabetes, minimize uncompensated care costs, and mitigate spending on other chronic disease complications caused by diabetes, like chronic kidney disease.

Addressing Diabetes and Food Insecurity: Community Health Workers and Clinic Based Food Referral Programs

This project aims to investigate vaccine hesitancy in relation to the COVID-19 pandemic and how social/structural barriers to vaccine access and lack of trustworthiness may impact equitable vaccination rates in African American individuals who reside in the Southeastern US. Current research shows that 46% of participants in a similar study expressed uncertain/low intent to receive the COVID-19 vaccine with factors such as distrust in the efficacy of vaccines influencing intentions most strongly. This project will analyze data from the Southern Community Cohort Study (SCCS), a prospective cohort of approximately 85,000 adults, to examine predisposing, enabling, and need factors from the Andersen Behavioral Model as predictors of vaccine uptake. The results of this study will be presented at scientific conferences, distributed to members of the community, and used to inform dissemination strategies.

Investigating How Social & Structural Barriers to Vaccine Access and Lack of Trustworthiness May Impact Vaccination Rates Among African Americans During the COVID-19 Pandemic

Background: Eating disorders (EDs) have some of the highest mortality rates reported among psychiatric illnesses and are exacerbated by stigmatization. Obesity is recognized as a worldwide epidemic, and weight stigma has been highly researched for its negative physical and mental health implications. However, despite the well-established link between weight stigma and the development of EDs, few qualitative studies exist that explore this relationship from the patient and provider perspective. This project seeks to further understand patients’ and providers’ perspectives of the complex relationship among obesity, EDs, and their stigmatization in healthcare settings.

Methods: Three groups were invited: people with self-disclosed EDs, people self-disclosing as overweight or obese, and providers in primary care or mental health care. Semi-structured interviews probed participant attitudes toward weight stigma, ED stigma, and how providers discuss weight and eating. Transcripts were analyzed by grounded theory methods to generate a codebook of identified themes.

Results: Twelve individuals (4 obese/overweight, 3 EDs, 6 providers; 1 both overweight and a provider) completed the interview. Themes were organized under seven domains: (1) weight stigma, (2) obesity stereotypes, (3) ED stigma, (4) ED stereotypes, (5) eating influences, (6) relationship between obesity and EDs, and (7) improving provider approaches to weight and eating.

Discussion: This qualitative analysis characterizes the different facets of weight stigma and ED stigma, as well as their relationship with eating, weight, and health. Healthcare providers must take patient-centered approaches when discussing these concepts to reduce stigma and better support these populations.

Weight Stigma in Providers: A Qualitative Study on Provider Attitudes Towards Eating Disorders and Obesity

Background
The Muslim community of Steelton, Pennsylvania faces many negative social determinants of health, centering around a lack of economic stability and cultural barriers to health. In a close collaboration between the Islamic Society of Greater Harrisburg (ISGH), Penn State Lion Care, Penn State Community Health, and Penn State Muslim Student Association (MSA), a health fair was established at the ISGH mosque to provide education and resources to the local Muslim community.
Methods
Planning was initiated 6 months in advance, which included establishing relationships with stakeholders, solidifying a time and location for the event, recruiting volunteers, marketing, and other logistical tasks. Volunteer recruitment occurred primarily through pre-established organizational networks and used mediums such as email, group messaging, and word-of- mouth. Event marketing included distributing event fliers at 6 different local mosques after Friday prayer for 3 weeks leading up to the event. The health fair included stations which were uniquely designed around community needs and were created and run by volunteers, who included medical students, residents, attending physicians, and community health staff. Stations included engaging informational posters and unique free giveaways such as sunscreen, hats, and informational brochures. A “health passport” system was created to further engage event attendees.
Results
The health fair lasted for 3 hours, in which 38 people attended. 31 attendees received an Influenza vaccine, 28 had their blood pressure read, and 11 had blood glucose read. 27 volunteers, 13 were Muslims. Three referrals were made to LionCare. A total of 12 patients needed translation services, which included English, French, Urdu, and Arabic
languages. Screenings included blood pressure and blood glucose levels, and flu shot administration. Information stations included: diabetes education, mental health awareness, women’s health, pediatric injury prevention, vaccination myths, exercise and nutrition, colon cancer screening, skin cancer prevention, and free clinic resources.
Conclusion
Successful elements of the health fair included working with diverse volunteers that spoke multiple languages to translate for patients, tailoring topics to the Muslim population’s health needs, encouraging engagement within the health fair through interactive activities, and providing care within a cultural context (i.e. private spaces for men and women, avoiding music inside the mosque, modest attire for volunteers, etc.).
Future improvements include pairing the health fair with an already established community event, such as Friday prayer, to help increase attendance. Since this was a first time event, establishing consistency and building a respectable reputation in the community can incentivize more attendance in the future.


Establishing a Health Fair at a Mosque for an Underserved Muslim Population

This study investigates the feasibility and impact of a 12-week intervention combining Ashtanga yoga and mindfulness-enhanced behavioral lifestyle educational practices on mental and physical health outcomes in community-dwelling South Asian immigrant women. Thirty participants, recruited from diverse community gatherings, engaged in weekly sessions comprising 90 minutes of yoga and 30 minutes of mindfulness-enhanced interventions. Participants’ were an average age of was 53±6.3 years, with a mean BMI of 28.5±4.2, indicating overweight. Recruitment was successful, with 28 (93%) completing the study, demonstrating high feasibility. Participant attendance and satisfaction were strong, reinforcing acceptability. Significant improvements were observed in self-reported questionnaires, including mindfulness facets, depression, sleep quality, self-esteem, and physical activity levels. Objective assessments revealed improvements in mobility, grip strength, cognitive function, and systolic blood pressure. These findings support the feasibility and potential benefits of the intervention in enhancing mental and physical health outcomes in this population.

Group-Led Yoga and Mindfulness Intervention to Improve Mental and Physical Health Outcomes in a High-Risk Minority Population: South Asian Middle- and Older-Aged Women


Key words: Barbershops, Mental Health, Emotional Impact, Therapist, Talk Therapy


Introduction: Mens' mental health, particularly in communities of color, is an unkempt public health issue. In the United States, 1 in 8 men are likely to be diagnosed with a mental health illness, but compared to their women counterparts, are 33% less likely to reach out for intervention from a healthcare professional for mental or general health. What’s more, men are 3.56 times more likely to commit suicide than women. These numbers are hyper intense in Fort Worth, TX. Intervention is desperately needed. Our project goal is to utilize volunteer mental health professionals to provide focus groups, education, and health screening services to barbershops in underserved communities in Fort Worth, TX. The hope is that men of color will be able to have talk therapy during their haircut while receiving resources and support that they would/could not otherwise acquire. We will measure the likelihood of the men seeking mental health services after acquiring resources during their haircut, and how important safe spaces like the barbershop are vital in dismantling barriers to access resources. 

Method: 26 question electronical survey that gauge participants knowledge and accessibility to mental health resources in FW. PHQ2 is incorporated into the survey and will be done to gauge if follow up with MH professionals is needed during or after the project. The screening will be administered via electronic survey on iPad. Surveys will provide a participant ID to privately follow up and/or refer participants with anonymity. We will evaluate the emotional impact the project had on the patrons who visited that day. Additionally, it will measure the likelihood that individuals who attended followed up to receive mental health or general health services in the subsequent month.

Results: in a sample, n=45 individuals 68% percent deny promoting wellness in their everyday life. Over 53% denote moderate stressors being their occupation (24) and 33% severe stressors being Social injustice/race/class (18). 22.2% do not confide with anyone when they feel overwhelmed. 15% do not feel safe anywhere. 42% screened positive for depression via PHQ2, 59% believe their barber is like a therapist, 59% talk to their barbers about sensitive topics they do not talk to anyone else about. 93% feel more optimistic and less stress after leaving the barbershop. 57% felt more reassured about accessing mental health resources after the conclusion of the project. 74% stated it is important for them to have a therapist that looks like them. 53% stated that after the barbershop event, they probably and/or definitely would consider seeking a mental health provider. 46% stated barbershops are important to communities because haircuts make you feel better about yourself; 46% stated as well that barbershops are a place we can strategize how to be better for our community. 

Conclusion: Barbershops are a powerful setting in the de-stigmatization of mental health of men from minority communities. It instills confidence to access said resources and mobilizes ownership of their mental wellness as well as their community. More work needs to be done in creating a network of diverse therapists that can treat the multifaceted needs of the community. Additionally, training sessions would be invaluable to treat barbers how to identify anxiety or depression as well as equip them with resources to refer patrons accordingly. 

References:
1. The National Institute of Mental Health. (2021). Men and Mental Health. https://www.nimh.nih.gov/health/topics/men-and-mental-health/index.shtml
2. Substance Abuse and Mental Health Services Administration. (2019). Mental Health: Culture, Race, and Ethnicity - A Supplement to Mental Health: A Report of the Surgeon General. https://www.ncbi.nlm.nih.gov/books/NBK44243/
3. National Alliance on Mental Illness. (2021). African American Mental Health. https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/Black-African-American
4. Ghafoori, B., Langer, D. A., & Hunter, S. J. (2020). Exploring the Role of Barbershops in Facilitating Men's Access to Mental Health Care. Journal of racial and ethnic health disparities, 7(4), 675–684. https://doi.org/10.1007/s40615-019-00662-9
5. Hankerson, S. H., Suite, D., & Bailey, R. K. (2018). Treatment Preferences for Depression in Men of Color Who Participate in Community-Based Health Screening Events. Journal of racial and ethnic health disparities, 5(3), 598–607. https://doi.org/10.1007


Barbershop Talk Therapy Project: A Quality Improvement Study on Therapy-Led
Focus Groups for Minority Males in Community-Driven Spaces

Background
In 2017, Charleston was reported as the fasted gentrifying city in the United States of America. Gentrification has been theorized to impact health through changes to the physical environment and changes to the social environment. Despite an overall increase in insurance coverage in the Tri-County Charleston Metropolitan area (Tri-County Area) in South Carolina, the number of premature deaths increased between the years of 2015 to 2020. 

Methods
Trident United Way provided a data set from the Community Health Needs Assessment Survey published in 2019. This study analyzed this Community Health Needs Assessment Report conducted by Trident United Way. Variables analyzed were self-reported reasons for limited healthcare access by race and ethnicity. Race/ethnicity was categorized as White, Hispanic, Black, and Other. Rao-Scott Chi Square tests were used to conduct all analyses. 

Results
Significant results indicated a difference by race/ethnicity for the following reasons for limited healthcare access: “Cultural/religious beliefs” (p=<.0001); “I don’t know how to access healthcare services (p=.034); “I do not know when I need to see a doctor” (p=.006); “Fear” (p=.010); “I do not trust doctors'' (p=.003), “I do not have insurance and cannot pay for services (<.001); “I have insurance, but I cannot afford the co-pay or deductibles” (p<.001); “I do not know how to sign up for health insurance” (p<.001); “Lack of transportation” (p<.001); and “Lack of knowledge” (p<.001). No significant difference was found for lack of available healthcare services or distance to healthcare services.

Conclusion
Findings indicate that many disparities exist by race/ethnicity related to reasons for limited healthcare access in the Charleston Tri-County area. The top three most significant reasons were related to economic effects and were the highest in the minority populations. It is also important to note that lack of knowledge and distrust in doctors in the Hispanic population were higher than the top 3 overall reasons. This may be due to language barriers and/or recent immigration status. No differences were found regarding availability of services or distance to services, indicating that other strategies are needed to increase access to care. The most significant reason for Caucasians regarding limited healthcare access was that even though they had insurance, they stated they could not afford to pay their co-pay or deductible. This was counterintuitive from the demographic data that showed that they were the race with the highest self-reported income and education level.

Social Determinants of Access to Healthcare Services in the Tri-County Charleston Metropolitan Area by Race/Ethnicity

Background
Preterm birth is a major medical concern in the United States. According to the National Center for Health Statistics, about 1 in every 10 (10.38%) infants born in the United States in 2022 was delivered preterm. Neighborhood deprivation has been reported to be associated with preterm birth and neighborhood violence may mediate the association. However, the mediating influence of neighborhood violence has been unexplored in medical studies. This study, using a geographically defined cohort of women in Richmond city, Virginia, aims to examine the mediating influence of neighborhood violence on the association between neighborhood deprivation and preterm birth.

Methods
Merged data from the vital statistics live birth records, police crime reports, and census data for Richmond city, Virginia, for a ten-year consecutive period of 2006 to 2015 were analyzed. Data had a 2-level hierarchical structure with individual live births nested in 66 census tracts. Neighborhood deprivation was measured using the Neighborhood Deprivation Index (NDI) based on a previously validated algorithm and it synthesizes multiple dimensions of the neighborhood socioeconomic context, allowing for comparisons across geographic areas. Neighborhood violence was measured as the violence rate (per 1000 youth population) for each census tract and preterm birth was measured as the birth of a baby before 37 completed weeks of gestation. Multilevel structural equation modeling was used to examine the mediating influence of neighborhood violence on the association between neighborhood deprivation and preterm birth and the direct and indirect effects and their associated 95% confidence intervals were recorded.

Results
Rate of preterm birth in the study population was 10.1% and the violence rate was 114.1 per 1000 youth population in Richmond city during the study period. The median NDI score across all census tracts was 0.09, with an interquartile range of –0.69 to 0.76. There was a significant direct effect between neighborhood deprivation and preterm birth (β=0.304, 95% CI=0.231, 0.377). However, the indirect effect of neighborhood deprivation on preterm birth through neighborhood violence was not significant (β=0.063, 95% CI= –0.025, 0.151).

Conclusions
There is insufficient evidence to show that neighborhood violence mediates the association between neighborhood deprivation and preterm birth in women in Richmond city, Virginia. However, findings lend support to previous studies that reported increased risk of preterm birth in women resident in deprived neighborhoods, as well as increased risk of neighborhood violence in deprived neighborhoods.


Next from AMA Research Challenge 2023

Trends in Provider Specialty for Urgent Care Visits Among Medicare Beneficiaries from 2011-2017

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