Health disparities and underserved populations: a potential solution, medical school partnerships with free clinics to improve curriculum

Implementing a Prenatal Oral Health Program for Dental Students: Lessons Learned

The Prenatal Oral Health Program (pOHP) was developed to educate dental students on prenatal oral health and promote access to dental care for pregnant women. Program advancement has occurred in support of quality improvement. This mixed-methods design combined quantitative data from fourth-year dental students who participated the pOHP (N = 81) and qualitative data from a student-faculty-staff focus group discussion (N = 7). Different clinical structures, appropriate leveling in the curriculum, management with a patient care coordinator, and inclusion of interprofessional learning experiences (IPE) were compared. The survey response rate was 96.4% (N = 81). Trends were noted between students who provided clinical care for a pregnant patient (31%) versus those who did not. Results indicated that an integrated clinic was preferred, though students who had treated a pOHP patient showed greater support for a standalone clinic model. Survey and focus group data agreed that pOHP should occur during the third-year dental school training; however, students with patient experience favored second-year placement. Survey and focus group data emphasize the importance of a patient care coordinator for clinical management and IPE as an essential learning element. Innovating new clinical models requires a period of evolution to determine preferred and sustainable infrastructure. Results reveal the advantages and disadvantages of various program implementation models and demonstrate that student perceptions were influenced by their clinical experiences. Study findings will inform implementation and guide other programs as they create and modify existing curricula to enhance prenatal oral health.

Association of Sociodemographic Characteristics With US Medical Student Attrition

Importance

Diversity in the medical workforce is critical to improve health care access and achieve equity for resource-limited communities. Despite increased efforts to recruit diverse medical trainees, there remains a large chasm between the racial and ethnic and socioeconomic composition of the patient population and that of the physician workforce.

Objective

To analyze student attrition from medical school by sociodemographic identities.

Design, Setting, and Participants

This retrospective cohort study included allopathic doctor of medicine (MD)-only US medical school matriculants in academic years 2014-2015 and 2015-2016. The analysis was performed from July to September 2021.

Main Outcomes and Measures

The main outcome was attrition, defined as withdrawal or dismissal from medical school for any reason. Attrition rate was explored across 3 self-reported marginalized identities: underrepresented in medicine (URiM) race and ethnicity, low income, and underresourced neighborhood status. Logistic regression was assessed for each marginalized identity and intersections across the 3 identities.

Results

Among 33 389 allopathic MD-only medical school matriculants (51.8% male), 938 (2.8%) experienced attrition from medical school within 5 years. Compared with non-Hispanic White students (423 of 18 213 [2.3%]), those without low income (593 of 25 205 [2.3%]), and those who did not grow up in an underresourced neighborhood (661 of 27 487 [2.4%]), students who were URiM (Hispanic [110 of 2096 (5.2%); adjusted odds ratio (aOR), 1.41; 95% CI, 1.13-1.77], non-Hispanic American Indian/Alaska Native/Native Hawaiian/Pacific Islander [13 of 118 (11.0%); aOR, 3.20; 95% CI, 1.76-5.80], and non-Hispanic Black/African American [120 of 2104 (5.7%); aOR, 1.41; 95% CI, 1.13-1.77]), those who had low income (345 of 8184 [4.2%]; aOR, 1.33; 95% CI, 1.15-1.54), and those from an underresourced neighborhood (277 of 5902 [4.6%]; aOR, 1.35; 95% CI, 1.16-1.58) were more likely to experience attrition from medical school. The rate of attrition from medical school was greatest among students with all 3 marginalized identities (ie, URiM, low income, and from an underresourced neighborhood), with an attrition rate 3.7 times higher than that among students who were not URiM, did not have low income, and were not from an underresourced neighborhood (7.3% [79 of 1086] vs 1.9% [397 of 20 353]; P < .001).

Conclusions and Relevance

This retrospective cohort study demonstrated a significant association of medical student attrition with individual (race and ethnicity and family income) and structural (growing up in an underresourced neighborhood) measures of marginalization. The findings highlight a need to retain students from marginalized groups in medical school.

Working with communities: Meeting the health needs of those living in vulnerable communities when Primary Health Care and Universal Health Care are not available

RATIONALE, AIMS, AND OBJECTIVES

The health care delivery model in the United States does not work; it perpetuates unequal access to care, favours treatment over prevention, and contributes to persistent health disparities and lack of insurance. The vast majority of those who suffer from preventable diseases and health disparities, and who are at greatest risk of not having insurance, are low-income minorities (Native Americans, Hispanics, and African-Americans) who live in high risk and vulnerable communities. The historical lack of support in the United States for Universal Health Care (UHC) and Primary Health Care (PHC)-with their emphasis on health care for all, population health, and social determinants of health-requires community health scientists to develop innovative local solutions for addressing unmet community health needs.

METHODS

We developed a model community health science approach for improving health in fragile communities, by combining community-oriented primary care (COPC), community-based participatory research (CBPR), asset-based community development, and service learning principles. During the past two decades, our team has collaborated with community residents, local leaders, and many different types of organizations, to address the health needs of vulnerable patients. The approach defines health as a social outcome, resulting from a combination of clinical science, collective responsibility, and informed social action.

RESULTS

From 2000 to 2020, we established a federally funded research programme for testing interventions to improve health outcomes in vulnerable communities, by working in partnership with community organizations and other stakeholders. The partnership goals were reducing chronic disease risk and multimorbidity, by stimulating lifestyle changes, increasing healthy behaviours and health knowledge, improving care seeking and patient self-management, and addressing the social determinants of health and population health. Our programmes have also provided structured community health science training in high-risk communities for hundreds of doctors in training.

CONCLUSION

Our community health science approach demonstrates that the factors contributing to health can only be addressed by working directly with and in affected communities to co-develop health care solutions across the broad range of causal factors. As the United States begins to consider expanding health care options consistent with PHC and UHC principles, our community health science experience provides useful lessons in how to engage communities to address the deficits of the current system. Perhaps the greatest assets US health care systems have for better addressing population health and the social determinants of health are the important health-related initiatives already underway in most local communities. Building partnerships based on local resources and ongoing social determinants of health initiatives is the key for medicine to meaningfully engage communities for improving health outcomes and reducing health disparities. This has been the greatest lesson we have learned the past two decades, has provided the foundation for our community health science approach, and accounts for whatever success we have achieved.

Identifying and tackling racial disparities in healthcare

ABSTRACT

The US healthcare system is plagued with inequities that disproportionately impact people of color and other marginalized communities. This article discusses some of the key reasons behind these historic and current health disparities, identifies key terms, and discusses strategies for nurses who are interested in allying with efforts to tackle inequity and racism in American healthcare.

In the Zoom Where It Happened: Telepractice and the Voice Clinic in 2020

Telemedicine-conveying medical information virtually for planning, diagnosis, or treatment-has been a part of the American medical system for over 100 years. A constantly evolving modality, telepractice was a supplemental care delivery system for most speech-language pathologists (SLPs) until March 2020 when the COVID-19 pandemic forced clinical operations to halt in-person activities and convert as much as possible to virtual platforms. The purpose of this article is to provide an overview of the need for telepractice prior to and beyond the current pandemic, the efficacy of telepractice for the voice-specialized SLP, limitations of telepractice, and best practices for providing care over telepractice with a specific focus on voice disorder diagnosis and treatment.

Managing Diabetes in Hard to Reach Populations: A Review of Telehealth Interventions

PURPOSE OF REVIEW

Diabetes mellitus is a leading chronic disease worldwide. Access to diabetes care varies widely and is influenced by multiple factors including social, geographic, and economic conditions. The use of technology to expand healthcare may bridge these barriers and improve access. Our aim was to review the evidence for the role of telehealth to expand access to quality diabetes care.

RECENT FINDINGS

There is evidence that application of technology-based programs to deliver healthcare are both feasible and effective. These programs are accepted by both patients and providers, can reduce healthcare costs, and may redress inequalities in healthcare access. Technology-based care models can improve disease management, enhance efficiency and clinical decision-making, promote patient self-management skills, and promote patient centered care. Future research should focus on implementation of technology-based healthcare delivery programs on a larger scale.

Street Medics: An innovative learning opportunity for UK medical students in a primary care outreach setting

It is well known that recruitment into general practice (GP) is low, particularly in deprived areas. Undergraduate medical students are encouraged to learn about health inequalities.However, teaching on this area has been perceived by some as uninspiring. Innovative teaching opportunities can engage students but more research is needed regarding exposure to deprived inner-city settings. Street Medics is an extra-curricular, educational initiative which enables students to join GPs doing street-outreach work. The aim of the study was to understand what motivates undergraduate medical students to engage with Street Medics and the impact of the experience. Focus group data were collected and thematically analysed. Motivating factor themes: appetite to explore; previous exposure including observation of perceived sub-optimal care to marginalised patients; perceived lack of exposure personally and in undergraduate teaching. Experience and impact themes: increased understanding of social determinants of health; change in perception; influence on career intentions; desire to incorporate into curriculum. Opportunities like Street Medics can supplement the undergraduate curriculum and not only challenge students' perceptions of marginalised patients but also ignite their enthusiasm for pursuing GP. By understanding the factors driving students' engagement in innovative educational opportunities, effective methods can be shared across undergraduate courses.

Student Pharmacists' Perspectives on Service-Learning Experiences in Free Clinics

Objective. To explore student pharmacists' perspectives on the value of pharmacy-related service-learning experiences focused on caring for underserved populations. Methods. Student pharmacists were required to complete a three-hour volunteer experience at a free clinic in western Pennsylvania. Reflective essays from all second- and third-year student pharmacists who participated in the required service-learning experience were deidentified. Essays were thematically analyzed to formulate a list of codes that represent dominant conceptual categories. Two independent coders read and coded all essays submitted from September 2015 to May 2017 using qualitative data analysis. Codes were evaluated for intercoder variability and discrepancies were mediated through discussion. Results. Four hundred twenty-two students submitted reflective essays: 222 essays were submitted by second-year students and 200 by third-year students. The prevailing themes reflected the professional obligation students felt to provide care to the underserved, empathy for underserved patients, perspectives on equitable health resource distribution, the value of service-learning experiences, growth in interprofessional awareness, and self-reported empowerment from the experience. Themes were consistent in the reflective essays of both second-year and third-year students. Third-year students' essays reflected a greater sense of self-assurance and confidence in their role at the free clinics. Students made connections between their didactic learning and experiential education. Conclusion. Student pharmacists valued their experiences working in underserved settings. Free clinics provide opportunities for student pharmacists to develop hands-on training as well as gain a broader perspective on underserved populations, health resource distribution, and the role of pharmacists.

A Cross-Sectional Study Evaluating the Use of Free Clinics in Syracuse, NY: Patient Demographics and Barriers to Accessing Healthcare in Traditional Settings

Free clinics provide healthcare to underserved patient populations, playing a critical role in the medical safety-net. Syracuse, New York has notable racial, socioeconomic, and educational disparities and is home to four free clinics. Little is known about these clinics' patient population. This study attempts to better define this population and the barriers they face accessing traditional care. We developed a 27-question survey investigating patient demographics, barriers to traditional healthcare, and experience at local free clinics. Our analysis included descriptive statistics, t-tests, one-way ANOVA and Chi square testing. Of 287 patients surveyed, 55% of patients were employed, 78% were uninsured, and 43% cited cost as their primary barrier to insurance. 29% rated their health as fair or poor. 21% had been to the Emergency Room (ER) in the past six months. 38% stated they would go to the ER if free clinics did not exist. Insurance coverage was unrelated to education or employment status (p = .52 and .81, respectively), but differed significantly between racial and ethnic groups (p < .007). Insured patients were more likely to have visited an ER in the past 6 months (p = .01), received preventive health services (p = .02), and seen a provider outside of the free clinic as compared to patients without insurance (p < .001). Free clinic patients represent a heterogeneous population with poor health indicators and several barriers to traditional care, especially cost. This information may aid public health agencies in developing policies to increase access to medical care and decrease morbidity and mortality among this population.

Opportunities for Community Health Worker Training to Improve Access to Health Care for Medicaid Enrollees

Limited access to care can negatively affect population health, which is particularly concerning for individuals of lower socioeconomic status. Shortages of US health care providers in areas that predominantly serve Medicaid enrollees contribute to a lack of access. The Ohio Medicaid Technical Assistance and Policy Program Healthcare Access Initiative was designed as a workforce development initiative to train and deploy community health workers (CHWs). The authors conducted 55 key informant interviews with preceptors, CHWs, and administrators across 5 sites with the specific aim of improving understanding of common barriers to and benefits of CHW program implementation across different CHW programs in Ohio. CHW programs reportedly act as a bridge between the patient and providers, and program benefits were reported for participants, organizations, and patients. This study found that CHW programs enabled training of health professionals that can empower participants while allowing them to also give back to their communities. Organizations employing CHWs reported being able to extend clinic services, increase utilization of community resources, and improve patient compliance through the efforts of CHWs; program impacts also led to increased patient support, patient education, and overall better care. To better integrate CHWs into health care organizations, organizations should focus on clearly defining the CHW role and ensuring adequate infrastructure to support CHW efforts.

Social Determinants of Health and Health Disparities Among Immigrants and their Children

In 2017, the United States (U.S.) foreign-born population was estimated to be 44.5 million, the highest share since 1910. It is unclear how many undocumented immigrants live in the U.S., but estimates in 2014 determined that there were at least 12.1 million. The immigrant population, particularly undocumented immigrants, has consistently been affected negatively by social determinants of health such as poverty, food and housing insecurity, lack of educational attainment, and challenges with health care access. Additionally, they face stigma and marginalization, difficulties with acculturation, and fear of deportation. Given these challenges that immigrants and their children face, physicians have a responsibility of assessing these social determinants of health and providing comprehensive care for this population.

Changes in pharmacy students' perceptions of underserved populations after a six-week clinical rotation in a federally qualified health center clinic

BACKGROUND AND PURPOSE

The primary objective of this study was to assess changes in pharmacy students' attitudes and perceptions toward providing care to underserved populations after a six-week clinical experience within a Federally Qualified Health Center (FQHC) clinic.

EDUCATIONAL ACTIVITY AND SETTING

A pre-post survey design was utilized to evaluate third- and fourth-year pharmacy students' attitudes and perceptions before and after a six-week clinical rotation providing direct patient care to underserved patients in FQHC clinics. Results were collected via self-administered online surveys that collected information on participants' (1) demographics, (2) past experiences interacting with underserved populations, (3) type of clinical activities completed during the rotation, and (4) personal opinions and perceptions of providing care to underserved populations.

FINDINGS

Responses to seven of the 18 attitudinal questions showed a statistically significant positive change from baseline, with three questions being related to educational satisfaction. Changes in attitudes for questions related to domains of personal impact and perceptions/barriers were also significant.

DISCUSSION/SUMMARY

Clinical rotations within an FQHC clinic can positively impact pharmacy students' attitudes towards underserved populations. If more students are exposed to direct patient care with underserved populations throughout their experiential training, the number of graduating student pharmacists that explore job opportunities within underserved areas may increase. Clinical rotations within an FQHC clinic can positively impact pharmacy students' attitudes towards underserved populations. If more students are exposed to direct patient care with underserved populations throughout their experiential training, the number of graduating student pharmacists that explore job opportunities within underserved areas may increase.

Health Disparities in Patients with Pulmonary Arterial Hypertension: A Blueprint for Action. An Official American Thoracic Society Statement

BACKGROUND

Health disparities have a major impact in the quality of life and clinical care received by minorities in the United States. Pulmonary arterial hypertension (PAH) is a rare cardiopulmonary disorder that affects children and adults and that, if untreated, results in premature death. The impact of health disparities in the diagnosis, treatment, and clinical outcome of patients with PAH has not been systematically investigated.

OBJECTIVES

The specific goals of this research statement were to conduct a critical review of the literature concerning health disparities in PAH, identify major research gaps and prioritize direction for future research.

METHODS

Literature searches from multiple reference databases were performed using medical subject headings and text words for pulmonary hypertension and health disparities. Members of the committee discussed the evidence and provided recommendations for future research.

RESULTS

Few studies were found discussing the impact of health disparities in PAH. Using recent research statements focused on health disparities, the group identified six major study topics that would help address the contribution of health disparities to PAH. Representative studies in each topic were discussed and specific recommendations were made by the group concerning the most urgent questions to address in future research studies.

CONCLUSIONS

At present, there are few studies that address health disparities in PAH. Given the potential adverse impact of health disparities, we recommend that research efforts be undertaken to address the topics discussed in the document. Awareness of health disparities will likely improve advocacy efforts, public health policy and the quality of care of vulnerable populations with PAH.

Occupational Health and Sleep Issues in Underserved Populations

Sleep disorders and occupational hazards, injuries, and illnesses impact an individual's overall health. In the United States, substantial racial, ethnic, and socioeconomic disparities exist in sleep and occupational health. Primary care physicians working in underserved communities should be aware of this disparity and target these higher-risk populations for focused evaluation and intervention.

Curricular integration of social medicine: a prospective for medical educators

In the United States, the health of a community falls on a continuum ranging from healthy to unhealthy and fluctuates based on several variables. Research policy and public health practice literature report substantial disparities in life expectancy, morbidity, risk factors, and quality of life, as well as persistence of these disparities among segments of the population. One such way to close this gap is to streamline medical education to better prepare our future physicians for our patients in underserved communities. Medical schools have the potential to close the gap when training future physicians by providing them with the principles of social medicine that can contribute to the reduction of health disparities. Curriculum reform and systematic formative assessment and evaluative measures can be developed to match social medicine and health disparities curricula for individual medical schools, thus assuring that future physicians are being properly prepared for residency and the workforce to decrease health inequities in the United States. We propose that curriculum reform includes an ongoing social medicine component for medical students. Continued exposure, practice, and education related to social medicine across medical school will enhance the awareness and knowledge for our students. This will result in better preparation for the zero mile stone residency set forth by the Accreditation Council of Graduate Medical Education and will eventually lead to the outcome of higher quality physicians in the United States to treat diverse populations.