Economic Determinants of Health Disparities and the Role of the Primary Care Provider

The economic determinants of adverse personal health outcomes and population level disparities pose a daunting challenge for primary care providers in promoting health for persons experiencing poverty and neighborhood deprivation. Until they are addressed, however, the health and economic well-being of persons experiencing neighborhood deprivation is not likely to be improved. There is growing evidence of effective interventions that primary care providers can adopt to address social and economic determinants of health. Primary care providers can participate in clinic and community-based approaches that target individual, neighborhood and social level drives of health and disparities.

Seminar: Scalable Preprocessing Tools for Exposomic Data Analysis

BACKGROUND

The exposome serves as a popular framework in which to study exposures from chemical and nonchemical stressors across the life course and the differing roles that these exposures can play in human health. As a result, data relevant to the exposome have been used as a resource in the quest to untangle complicated health trajectories and help connect the dots from exposures to adverse outcome pathways.

OBJECTIVES

The primary aim of this methods seminar is to clarify and review preprocessing techniques critical for accurate and effective external exposomic data analysis. Scalability is emphasized through an application of highly innovative combinatorial techniques coupled with more traditional statistical strategies. The Public Health Exposome is used as an archetypical model. The novelty and innovation of this seminar's focus stem from its methodical, comprehensive treatment of preprocessing and its demonstration of the positive effects preprocessing can have on downstream analytics.

DISCUSSION

State-of-the-art technologies are described for data harmonization and to mitigate noise, which can stymie downstream interpretation, and to select key exposomic features, without which analytics may lose focus. A main task is the reduction of multicollinearity, a particularly formidable problem that frequently arises from repeated measurements of similar events taken at various times and from multiple sources. Empirical results highlight the effectiveness of a carefully planned preprocessing workflow as demonstrated in the context of more highly concentrated variable lists, improved correlational distributions, and enhanced downstream analytics for latent relationship discovery. The nascent field of exposome science can be characterized by the need to analyze and interpret a complex confluence of highly inhomogeneous spatial and temporal data, which may present formidable challenges to even the most powerful analytical tools. A systematic approach to preprocessing can therefore provide an essential first step in the application of modern computer and data science methods. https://doi.org/10.1289/EHP12901.

The association between cardiovascular disease and breast and gynecologic cancers among black female patients

INTRODUCTION

Little is known about whether a breast or gynecologic cancer diagnosis increases long-term cardiovascular disease (CVD) risk among Black females. The purpose of this study was to determine whether a breast or gynecologic cancer diagnosis is associated with CVD risk and identify determinants of subsequent CVD risk among Black females with an incident breast or gynecologic cancer diagnosis.

METHODS

Using the Southern Community Cohort Study data from 2002-2016, this study was designed to analyze CVD incidence among Black females without cancer or CVD at enrollment. Cox proportional hazards regression models with or without covariates were used to explore the relationship between a breast or gynecologic cancer diagnosis and CVD risk among women without cancer as well as without CVD at enrollment (N=11,486). In addition, Cox proportional hazards regression models, excluding those who developed CVD before breast and gynecologic cancer diagnosis and those with other types of cancers, were used to assess determinants of CVD risk among breast and gynecologic cancer survivors.

RESULTS

Of 11,486 Black females, 531 developed a breast or gynecological cancer (4.6%) over a median follow-up of 140 months (interquartile range: 123-159 months). Compared to women without cancer, women with a breast or gynecological cancers had greater than 20% higher risk of incident CVD during the follow-up period. Without adjusting for covariates, positive association between CVD risk and breast cancer was observed (hazard ratio (HR) = 1.24; 95% confidence interval (CI) = 1.11 - 1.39; p < 0.001); as well as between CVD risk and a gynecological cancer (HR = 1.23; 95% CI = 1.03 - 1.46; p = 0.021). Yet, after adjusting for covariates, CVD risk was only significantly associated with breast cancer (p = 0.001) but not gynecologic cancer. In cancer case-only analyses, CVD risk was significantly increasing with age (p < 0.05).

CONCLUSIONS

Like study populations of predominantly White females, our results suggest that, adjusting for covariates, Black females possess a higher risk of CVD following a breast cancer diagnosis compared to women who did not develop breast cancer. Our results suggest a need for active CVD surveillance in the cancer survivorship phase.

COVID-19 Vaccine Hesitancy and Uptake among Minority Populations in Tennessee

COVID-19 vaccine hesitancy and uptake among Southern states in the US has been problematic throughout the pandemic. To characterize COVID-19 vaccine hesitancy and uptake among medically underserved communities in Tennessee. We surveyed 1482 individuals targeting minority communities in Tennessee from 2 October 2021 to 22 June 2022. Participants who indicated that they did not plan to receive or were unsure whether to receive the COVID-19 vaccine were considered vaccine-hesitant. Among participants, 79% had been vaccinated, with roughly 5.4% not likely at all to be vaccinated in the next three months from the date that the survey was conducted. When focusing particularly on Black/AA people and white people, our survey results revealed a significant association between race (Black/AA, white, or people of mixed Black/white ancestry) and vaccination status (vaccinated or unvaccinated) (p-value = 0.013). Approximately 79.1% of all participants received at least one dose of a COVID-19 vaccine. Individuals who were concerned with personal/family/community safety and/or wanted a return to normalcy were less likely to be hesitant. The study found that the major reasons cited for refusing the COVID-19 vaccines were distrust in vaccine safety, concerns about side effects, fear of needles, and vaccine efficacy.

Vaccine Confidence and Uptake of the Omicron Bivalent Booster in Tennessee: Implications for Vulnerable Populations

The COVID-19 Omicron variant and its subvariants are now the dominant variants circulating in the US. Therefore, the original COVID-19 vaccine cannot offer full protection. Instead, vaccines that target the spike proteins of the Omicron variants are warranted. Hence, the FDA recommended the development of a bivalent booster. Unfortunately, despite the safety and immunogenicity of the Omicron bivalent boosters from Pfizer and Moderna, uptake in the US has been poor. At this time, only 15.8% of individuals in the US aged five and older have received the Omicron bivalent booster (OBB). The rate is 18% for those aged 18 and older. Poor vaccine confidence and booster uptake are often fueled by misinformation and vaccine fatigue. These result in more problems associated with vaccine hesitancy, which are particular prevalent in Southern states in the US. In Tennessee, the OBB vaccination rate for eligible recipients is only 5.88% at time of writing (16 February 2023). In this review, we discuss (1) the rationale for developing the OBBs; (2) the efficacy and safety of the bivalent boosters; (3) the adverse events associated with these boosters; (4) vaccine hesitancy associated with the OBBs uptake in Tennessee; (5) implications for vulnerable populations, disparities in uptake of OBBs in Tennessee, and strategies to improve vaccine confidence and OBB uptake. In support of public health, it is essential that we continue to provide education, awareness, and vaccine access to the vulnerable and medically underserved populations in Tennessee. Receiving the OBBs is the most effective method to date of protecting the public against severe COVID disease, hospitalization, and death.

Transforming Medical Education to Provide Gender-Affirming Care for Transgender and Gender-Diverse Patients: A Policy Brief

Transgender and gender-diverse (TGD) patients experience a greater burden of health disparities compared with their heterosexual/cisgender counterparts. Some of the poorer health outcomes observed in these populations are known to be associated with the prevalence of implicit bias, bullying, emotional distress, alcoholism, drug abuse, intimate partner violence, sexually transmitted infections (eg, human immunodeficiency virus and human papilloma virus), and cancer. The TGD populations face unique barriers to receiving both routine and gender-affirming health care (acquiring hormones and gender-affirming surgeries). Additional barriers to implementing affirming care training for TGD patients are lack of expertise among medical education faculty and preceptors both in undergraduate and in graduate medical education programs. Drawing on a systematic review of the literature, we propose a policy brief aimed at raising awareness about gender-affirming care among education planners and policy makers in government and advisory bodies.

The Current State of Antiracism Curricula in Undergraduate and Graduate Medical Education: A Qualitative Study of US Academic Health Centers

PURPOSE

We undertook a study to evaluate the current state of pedagogy on antiracism, including barriers to implementation and strengths of existing curricula, in undergraduate medical education (UME) and graduate medical education (GME) programs in US academic health centers.

METHODS

We conducted a cross-sectional study with an exploratory qualitative approach using semistructured interviews. Participants were leaders of UME and GME programs at 5 institutions participating in the Academic Units for Primary Care Training and Enhancement program and 6 affiliated sites from November 2021 to April 2022.

RESULTS

A total of 29 program leaders from the 11 academic health centers participated in this study. Three participants from 2 institutions reported the implementation of robust, intentional, and longitudinal antiracism curricula. Nine participants from 7 institutions described race and antiracism-related topics integrated into health equity curricula. Only 9 participants reported having "adequately trained" faculty. Participants mentioned individual, systemic, and structural barriers to implementing antiracism-related training in medical education such as institutional inertia and insufficient resources. Fear related to introducing an antiracism curriculum and undervaluing of this curriculum relative to other content were identified. Through learners and faculty feedback, antiracism content was evaluated and included in UME and GME curricula. Most participants identified learners as a stronger voice for transformation than faculty; antiracism content was mainly included in health equity curricula.

CONCLUSIONS

Inclusion of antiracism in medical education requires intentional training, focused institutional policies, enhanced foundational awareness of the impact of racism on patients and communities, and changes at the level of institutions and accreditation bodies.

Curricular Interventions in Medical Schools: Maximizing Community Engagement Through Communities of Practice

This article explains the importance of a communities of practice (CoP) model for continually aligning medical education and clinical transformation with contemporary health issues. It describes the evolution and advantages of using CoP as a model for transforming medical education and clinical practice and applies the CoP methodology to addressing the changing needs of socially vulnerable populations (LGBTQ [lesbian, gay, bisexual, transgender, and queer/questioning], persons experiencing homelessness, and migrant farm workers). In conclusion, this article describes CoP-led activities, achievements, and value creation in medical education by the National Center for Medical Education Development and Research established at the Meharry Medical College.

An Analysis of COVID-19 Mortality During the Dominancy of Alpha, Delta, and Omicron in the USA

BACKGROUND

The objective of the study was to measure the risk of death due to COVID-19 in relation to individuals' characteristics, and severity of their disease during the dominant periods of Alpha, Delta, and Omicron variants have influenced mortality rates.

METHODS

This study was conducted using COVID-19 Centers for Disease Control and Prevention (CDC) Case Surveillance Public Data Taskforce for 57 states, and United States territories between January 1, 2020 and March 20, 2022. Multivariable binary Hyperbolastic regression of type I was used to analyzes the data.

RESULTS

Seniors and ICU-admitted patients had the highest risk of death. For each additional percent increase in fully vaccinated individuals, the odds of death deceased by 1%. The odds of death prior to vaccine availability, compared to post vaccine availability, was 1.27. When comparing the time periods each variant was dominant, the odds of death was 3.45-fold higher during Delta compared to Alpha. All predictor variables had P-values ≤.001.

CONCLUSION

There was a noticeable difference in the odds of death among subcategories of age, race/ethnicity, sex, PMCs, hospitalization, ICU, vaccine availability, variant, and percent of fully vaccinated individuals.

The COVID-19 Vaccine and Pregnant Minority Women in the US: Implications for Improving Vaccine Confidence and Uptake

The American College of Obstetricians and Gynecologists (AGOG) recommends the FDA-approved Pfizer and Moderna mRNA COVID-19 vaccines and boosters for all eligible pregnant women in the US. However, COVID-19 vaccine confidence and uptake among pregnant minority women have been poor. While the underlying reasons are unclear, they are likely to be associated with myths and misinformation about the vaccines. Direct and indirect factors that deter minority mothers in the US from receiving the mRNA COVID-19 vaccines require further investigation. Here, we examine the historical perspectives on vaccinations during pregnancy. We will examine the following aspects: (1) the influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccinations during pregnancy; (2) the exclusion of pregnant and lactating women from COVID-19 vaccine trials; (3) COVID-19 vaccine safety during pregnancy, obstetric complications associated with symptomatic COVID-19 during pregnancy, COVID-19 vaccine hesitancy among pregnant minority women, and racial disparities experienced by pregnant minority women due to the COVID-19 pandemic as well as their potential impact on pregnancy care; and (4) strategies to improve COVID-19 vaccine confidence and uptake among pregnant minority women in the US. COVID-19 vaccine hesitancy among minority mothers can be mitigated by community engagement efforts that focus on COVID-19 vaccine education, awareness campaigns by trusted entities, and COVID-19-appropriate perinatal counseling aimed to improve COVID-19 vaccine confidence and uptake.

Engaging Black men who have sex with men (MSM) in the South in identifying strategies to increase PrEP uptake

BACKGROUND

Promotion, uptake, and adherence of pre-exposure prophylaxis (PrEP) is paramount to ending the HIV epidemic among young Black men who have sex with men in the South. The purpose of this study was to explore strategies needed for and barriers to PrEP uptake needed to achieve HIV prevention goals identified in the U.S. Department of Health & Human Services initiative to reduce new HIV infections in the United States by 90 percent by 2030.

METHOD

Young adults (n = 25) between the ages of 15-34 were recruited from community-based organizations in Memphis to participate in four focus group discussions. Discussion topics included motivations, barriers, and facilitators to PrEP use. Data were analyzed using thematic analysis.

RESULTS

All (100%) of participants self-identified as HIV-negative, Black (96%), men who have sex with men (96%), and currently prescribed PrEP/Truvada (60%). Themes identified for increasing uptake included 1) trusted peers, 2) relatable healthcare provider (e.g., Historically Black College and University (HBCU) trained, LGBTQ), and 3) use of social media. Mislabeling of PrEP as promiscuity promoting and limitations with PrEP marketing (e.g., solely LGBTQ) were recognized as barriers that perpetuated stigma.

CONCLUSION

Findings suggest the importance of increasing awareness among health professions students matriculating at HBCUs of their perceived role as relatable healthcare providers by Black MSM; working closely with couples; and crafting of PrEP messaging that is non-stigmatizing. Findings will inform public health interventions for young Black MSM and facilitate HIV prevention efforts with other groups disproportionally affected by HIV in the South.

Maternal childhood trauma and prenatal stressors are associated with child behavioral health

Maternal adversity and prenatal stress confer risk for child behavioral health problems. Few studies have examined this intergenerational process across multiple dimensions of stress; fewer have explored potential protective factors. Using a large, diverse sample of mother-child dyads, we examined associations between maternal childhood trauma, prenatal stressors, and offspring socioemotional-behavioral development, while also examining potential resilience-promoting factors. The Conditions Affecting Neurocognitive Development and Learning and Early Childhood (CANDLE) study prospectively followed 1503 mother-child dyads (65% Black, 32% White) from pregnancy. Exposures included maternal childhood trauma, socioeconomic risk, intimate partner violence, and geocode-linked neighborhood violent crime during pregnancy. Child socioemotional-behavioral functioning was measured via the Brief Infant Toddler Social Emotional Assessment (mean age = 1.1 years). Maternal social support and parenting knowledge during pregnancy were tested as potential moderators. Multiple linear regressions (N = 1127) revealed that maternal childhood trauma, socioeconomic risk, and intimate partner violence were independently, positively associated with child socioemotional-behavioral problems at age one in fully adjusted models. Maternal parenting knowledge moderated associations between both maternal childhood trauma and prenatal socioeconomic risk on child problems: greater knowledge was protective against the effects of socioeconomic risk and was promotive in the context of low maternal history of childhood trauma. Findings indicate that multiple dimensions of maternal stress and adversity are independently associated with child socioemotional-behavioral problems. Further, modifiable environmental factors, including knowledge regarding child development, can mitigate these risks. Both findings support the importance of parental screening and early intervention to promote child socioemotional-behavioral health.

Big Data to Knowledge Analytics Reveals the Zika Virus Epidemic as Only One of Multiple Factors Contributing to a Year-Over-Year 28-Fold Increase in Microcephaly Incidence

During the 2015-2016 Zika Virus (ZIKV) epidemic in Brazil, the geographical distributions of ZIKV infection and microcephaly outbreaks did not align. This raised doubts about the virus as the single cause of the microcephaly outbreak and led to research hypotheses of alternative explanatory factors, such as environmental variables and factors, agrochemical use, or immunizations. We investigated context and the intermediate and structural determinants of health inequalities, as well as social environment factors, to determine their interaction with ZIKV-positive- and ZIKV-negative-related microcephaly. The results revealed the identification of 382 associations among 382 nonredundant variables of Zika surveillance, including multiple determinants of environmental public health factors and variables obtained from 5565 municipalities in Brazil. This study compared those factors and variables directly associated with microcephaly incidence positive to ZIKV and those associated with microcephaly incidence negative to ZIKV, respectively, and mapped them in case and control subnetworks. The subnetworks of factors and variables associated with low birth weight and birthweight where birth incidence served as an additional control were also mapped. Non-significant differences in factors and variables were observed, as were weights of associations between microcephaly incidence, both positive and negative to ZIKV, which revealed diagnostic inaccuracies that translated to the underestimation of the scope of the ZIKV outbreak. A detailed analysis of the patterns of association does not support a finding that vaccinations contributed to microcephaly, but it does raise concerns about the use of agrochemicals as a potential factor in the observed neurotoxicity arising from the presence of heavy metals in the environment and microcephaly not associated with ZIKV. Summary: A comparative network inferential analysis of the patterns of variables and factors associated with Zika virus infections in Brazil during 2015-2016 coinciding with a microcephaly epidemic identified multiple contributing determinants. This study advances our understanding of the cumulative interactive effects of exposures to chemical and non-chemical stressors in the built, natural, physical, and social environments on adverse pregnancy and health outcomes in vulnerable populations.

Breakthrough COVID-19 Infections in the US: Implications for Prolonging the Pandemic

The incidence of COVID-19 breakthrough infections-an infection that occurs after you have been vaccinated-has increased in frequency since the Delta and now Omicron variants of the SARS-CoV-2 coronavirus have become the dominant strains transmitted in the United States (US). Evidence suggests that individuals with breakthrough infections, though rare and expected, may readily transmit COVID-19 to unvaccinated populations, posing a continuing threat to the unvaccinated. Here, we examine factors contributing to breakthrough infections including a poor immune response to the vaccines due to the fact of advanced age and underlying comorbidities, the natural waning of immune protection from the vaccines over time, and viral variants that escape existing immune protection from the vaccines. The rise in breakthrough infections in the US and how they contribute to new infections, specifically among the unvaccinated and individuals with compromised immune systems, will create the need for additional booster vaccinations or development of modified vaccines that directly target current variants circulating among the general population. The need to expedite vaccination among the more than 49.8 million unvaccinated eligible people in the US is critical.

Affirming and Inclusive Care Training for Medical Students and Residents to Reducing Health Disparities Experienced by Sexual and Gender Minorities: A Systematic Review

Purpose

Providing inclusive and comprehensive gender-affirming care is critical to reducing health disparities (gaps in care) experienced by sexual and gender minorities (SGM). Currently, little is known about how medical students and residents are being trained to address the health needs of SGM persons or of the most effective methods.

Methods

We conducted a systematic review of the research literature from 2000 to 2020 on the effectiveness of teaching medical students and residents on knowledge, attitudes, and skills in addressing the health of SGM persons and the strength of the research sample, design, and methods used.

Results

We identified a total of 36 articles that assessed the impact of medical student and resident education on knowledge, comfort, attitudes, confidence, and skills in working with SGM patients. All studies utilized quasi-experimental designs, and found efficacious results. No study examined the impact of training on patient outcomes.

Conclusion

Future studies will need to be powered and designed to assess the impact of training on patient outcomes.

Examining the Drivers of Racial/Ethnic Disparities in Non-Adherence to Antihypertensive Medications and Mortality Due to Heart Disease and Stroke: A County-Level Analysis

Background: Prior research has identified disparities in anti-hypertensive medication (AHM) non-adherence between Black/African Americans (BAAs) and non-Hispanic Whites (nHWs) but the role of determinants of health in these gaps is unclear. Non-adherence to AHM may be associated with increased mortality (due to heart disease and stroke) and the extent to which such associations are modified by contextual determinants of health may inform future interventions. Methods: We linked the Centers for Disease Control and Prevention (CDC) Atlas of Heart Disease and Stroke (2014-2016) and the 2016 County Health Ranking (CHR) dataset to investigate the associations between AHM non-adherence, mortality, and determinants of health. A proportion of days covered (PDC) with AHM < 80%, was considered as non-adherence. We computed the prevalence rate ratio (PRR)-the ratio of the prevalence among BAAs to that among nHWs-as an index of BAA-nHW disparity. Hierarchical linear models (HLM) were used to assess the role of four pre-defined determinants of health domains-health behaviors, clinical care, social and economic and physical environment-as contributors to BAA-nHW disparities in AHM non-adherence. A Bayesian paradigm framework was used to quantify the associations between AHM non-adherence and mortality (heart disease and stroke) and to assess whether the determinants of health factors moderated these associations. Results: Overall, BAAs were significantly more likely to be non-adherent: PRR = 1.37, 95% Confidence Interval (CI):1.36, 1.37. The four county-level constructs of determinants of health accounted for 24% of the BAA-nHW variation in AHM non-adherence. The clinical care (β = -0.21, p < 0.001) and social and economic (β = -0.11, p < 0.01) domains were significantly inversely associated with the observed BAA-nHW disparity. AHM non-adherence was associated with both heart disease and stroke mortality among both BAAs and nHWs. We observed that the determinants of health, specifically clinical care and physical environment domains, moderated the effects of AHM non-adherence on heart disease mortality among BAAs but not among nHWs. For the AHM non-adherence-stroke mortality association, the determinants of health did not moderate this association among BAAs; the social and economic domain did moderate this association among nHWs. Conclusions: The socioeconomic, clinical care and physical environmental attributes of the places that patients live are significant contributors to BAA-nHW disparities in AHM non-adherence and mortality due to heart diseases and stroke.

Trending the evidence on opioid use disorder (OUD) continuum of care among rural American Indian/Alaskan Native (AI/AN) tribes: A systematic scoping review

BACKGROUND

American Indian/Alaskan Native (AI/AN) communities are second only to White Americans in mortality from opioid use disorder (OUD), while the smallest racial/ethnic minority population group in the USA. Those in rural communities experience significant health care disparities, including poorer treatment access for substance use disorder. This systematic scoping review aimed to trend the emerging evidence on opioid use disorder (OUD) management among rural AI/AN communities as well as workforce training needs.

METHOD

We searched the Medline, Embase, PsycInfo, SSCI, and Digital theses databases for empirical study publications on OUD management among AI/AN rural communities across the continuum of prevention, treatment and care. Eight studies met the following criteria: (a) focused on OUD; (b) sampled rural AI/AN members; (c) investigated prevention, treatment and/or care perspectives and/or practices or health provider preparation; and (d) published during the period 2009-2020. Included studies met the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) quality control standards.

FINDINGS

Six of eight of the studies (75%) were surveys with community members and other stakeholders on OUD management within rural AI/AN communities rather than active interventions within this population. Moreover, five of eight of the studies (63%) reported a preference for culturally grounded health and wellness interventions with rural AI/AN, involving families, and community interventionists, utilizing community reinforcement approaches. Three of eight studies (37.5%) reported need for the cultural adaption of medication-assisted treatments (MAT) and use of culturally informed recovery care approaches. One of eight studies (12.5%) proposed to use culturally adapted contingency management behavioral approaches for OUD treatment and recovery care.

CONCLUSION

The evidence is trending to endorse culturally adapted OUD management with rural AI/AN communities, prioritizing prevention education, and use of MAT with cultural adaptation and whole person approaches to sustainable recovery care. Mental health care should be a part OUD prevention, treatment and recovery care in rural AI/AN rural communities.

Pre-Exposure Prophylaxis Training among Medical Schools in the United States

Pre-Exposure Prophylaxis (PrEP) has been shown to be an effective method of HIV prevention for men who have sex with-men (MSM) and -transgender women (MSTGWs), serodiscordant couples, and injection drug users; however fewer than 50 000 individuals currently take this regimen. Knowledge of PrEP is low among healthcare providers and much of this lack of knowledge stems from the lack or exposure to PrEP in medical school. We conducted a cross sectional survey of medical schools in the United States to assess the degree to which PrEP for HIV prevention is taught. The survey consisted Likert scale questions assessing how well the students were prepared to perform each skill associated with PrEP delivery, as well as how PrEP education was delivered to students. We contacted 141 medical schools and 71 responded to the survey (50.4%). PrEP education was only reported to be offered at 38% of schools, and only 15.4% reported specific training for Lesbian, Gay, Bisexual, and Transgender (LGBT) patients. The most common delivery methods of PrEP content were didactic sessions with 11 schools reporting this method followed by problem-based learning, direct patient contact, workshops, and small group discussions. Students were more prepared to provide PrEP to MSM compared to other high-risk patients. Few medical schools are preparing their students to prescribe PrEP upon graduation. Further, there is a need to increase the number of direct patient contacts or simulations for students to be better prepared.

Recommendations for Increasing Physician Provision of Pre-Exposure Prophylaxis: Implications for Medical Student Training

There is growing evidence that pre-exposure prophylaxis (PrEP) prevents HIV acquisition. However, in the United States, approximately only 4% of people who could benefit from PrEP are currently receiving it, and it is estimated only 1 in 5 physicians has ever prescribed PrEP. We conducted a scoping review to gain an understanding of physician-identified barriers to PrEP provision. Four overarching barriers presented in the literature: Purview Paradox, Patient Financial Constraints, Risk Compensation, and Concern for ART Resistance. Considering the physician-identified barriers, we make recommendations for how physicians and students may work to increase PrEP knowledge and competence along each stage of the PrEP cascade. We recommend adopting HIV risk assessment as a standard of care, improving physician ability to identify PrEP candidates, improving physician interest and ability in encouraging PrEP uptake, and increasing utilization of continuous care management to ensure retention and adherence to PrEP.

Structural and Social Determinants of Health Factors Associated with County-Level Variation in Non-Adherence to Antihypertensive Medication Treatment

Background: Non-adherence to antihypertensive medication treatment (AHM) is a complex health behavior with determinants that extend beyond the individual patient. The structural and social determinants of health (SDH) that predispose populations to ill health and unhealthy behaviors could be potential barriers to long-term adherence to AHM. However, the role of SDH in AHM non-adherence has been understudied. Therefore, we aimed to define and identify the SDH factors associated with non-adherence to AHM and to quantify the variation in county-level non-adherence to AHM explained by these factors. Methods: Two cross-sectional datasets, the Centers for Disease Control and Prevention (CDC) Atlas of Heart Disease and Stroke (2014–2016 cycle) and the 2016 County Health Rankings (CHR), were linked to create an analytic dataset. Contextual SDH variables were extracted from the CDC-CHR linked dataset. County-level prevalence of AHM non-adherence, based on Medicare fee-for-service beneficiaries’ claims data, was extracted from the CDC Atlas dataset. The CDC measured AHM non-adherence as the proportion of days covered (PDC) with AHM during a 365 day period for Medicare Part D beneficiaries and aggregated these measures at the county level. We applied confirmatory factor analysis (CFA) to identify the constructs of social determinants of AHM non-adherence. AHM non-adherence variation and its social determinants were measured with structural equation models. Results: Among 3000 counties in the U.S., the weighted mean prevalence of AHM non-adherence (PDC < 80%) in 2015 was 25.0%, with a standard deviation (SD) of 18.8%. AHM non-adherence was directly associated with poverty/food insecurity (β = 0.31, P-value < 0.001) and weak social supports (β = 0.27, P-value < 0.001), but inversely with healthy built environment (β = −0.10, P-value = 0.02). These three constructs explained one-third (R² = 30.0%) of the variation in county-level AHM non-adherence. Conclusion: AHM non-adherence varies by geographical location, one-third of which is explained by contextual SDH factors including poverty/food insecurity, weak social supports and healthy built environments.

Use of an Exposome Approach to Understand the Effects of Exposures From the Natural, Built, and Social Environments on Cardio-Vascular Disease Onset, Progression, and Outcomes

Obesity, diabetes, and hypertension have increased by epidemic proportions in recent years among African Americans in comparison to Whites resulting in significant adverse cardiovascular disease (CVD) disparities. Today, African Americans are 30% more likely to die of heart disease than Whites and twice as likely to have a stroke. The causes of these disparities are not yet well-understood. Improved methods for identifying underlying risk factors is a critical first step toward reducing Black:White CVD disparities. This article will focus on environmental exposures in the external environment and how they can lead to changes at the cellular, molecular, and organ level to increase the personal risk for CVD and lead to population level CVD racial disparities. The external environment is defined in three broad domains: natural (air, water, land), built (places you live, work, and play) and social (social, demographic, economic, and political). We will describe how environmental exposures in the natural, built, and social environments "get under the skin" to affect gene expression though epigenetic, pan-omics, and related mechanisms that lead to increased risk for adverse CVD health outcomes and population level disparities. We also will examine the important role of metabolomics, proteomics, transcriptomics, genomics, and epigenomics in understanding how exposures in the natural, built, and social environments lead to CVD disparities with implications for clinical, public health, and policy interventions. In this review, we apply an exposome approach to Black:White CVD racial disparities. The exposome is a measure of all the exposures of an individual across the life course and the relationship of those exposures to health effects. The exposome represents the totality of exogenous (external) and endogenous (internal) exposures from conception onwards, simultaneously distinguishing, characterizing, and quantifying etiologic, mediating, moderating, and co-occurring risk and protective factors and their relationship to disease. Specifically, it assesses the biological mechanisms and underlying pathways through which chemical and non-chemical environmental exposures are associated with CVD onset, progression and outcomes. The exposome is a promising approach for understanding the complex relationships among environment, behavior, biology, genetics, and disease phenotypes that underlie population level, Black: White CVD disparities.

The Effects of Social, Personal, and Behavioral Risk Factors and PM2.5 on Cardio-Metabolic Disparities in a Cohort of Community Health Center Patients

(1) Background: Cardio-metabolic diseases (CMD), including cardiovascular disease, stroke, and diabetes, have numerous common individual and environmental risk factors. Yet, few studies to date have considered how these multiple risk factors together affect CMD disparities between Blacks and Whites. (2) Methods: We linked daily fine particulate matter (PM2.5) measures with survey responses of participants in the Southern Community Cohort Study (SCCS). Generalized linear mixed modeling (GLMM) was used to estimate the relationship between CMD risk and social-demographic characteristics, behavioral and personal risk factors, and exposure levels of PM2.5. (3) Results: The study resulted in four key findings: (1) PM2.5 concentration level was significantly associated with reported CMD, with risk rising by 2.6% for each µg/m3 increase in PM2.5; (2) race did not predict CMD risk when clinical, lifestyle, and environmental risk factors were accounted for; (3) a significant variation of CMD risk was found among participants across states; and (4) multiple personal, clinical, and social-demographic and environmental risk factors played a role in predicting CMD occurrence. (4) Conclusions: Disparities in CMD risk among low social status populations reflect the complex interactions of exposures and cumulative risks for CMD contributed by different personal and environmental factors from natural, built, and social environments.

Application of the Public Health Exposome Framework to Estimate Phenotypes of Resilience in a Model Ohio African-American Women's Cohort

We report integration of the United States Environmental Protection Agency's (USEPA) United States Environmental Justice Screen (EJSCREEN) database with our Public Health Exposome dataset to interrogate 9232 census blocks to model the complexity of relationships among environmental and socio-demographic variables toward estimating adverse pregnancy outcomes [low birth weight (LBW) and pre-term birth (PTB)] in all Ohio counties. Using a hill-climbing algorithm in R software, we derived a Bayesian network that mapped all controlled associations among all variables available by applying a mapping algorithm. The results revealed 17 environmental and socio-demographic variables that were represented by nodes containing 69 links accounting for a network with 32.85% density and average degree of 9.2 showing the most connected nodes in the center of the model. The model predicts that the socio-economic variables low income, minority, and under age five populations are correlated and associated with the environmental variables; particulate matter (PM_2.5) level in air, proximity to risk management facilities, and proximity to direct discharges in water are linked to PTB and LBW in 88 Ohio counties. The methodology used to derive significant associations of chemical and non-chemical stressors linked to PTB and LBW from indices of geo-coded environmental neighborhood deprivation serves as a proxy for design of an African-American women's cohort to be recruited in Ohio counties from federally qualified community health centers within the 9232 census blocks. The results have implications for the development of severity scores for endo-phenotypes of resilience based on associations and linkages for different chemical and non-chemical stressors that have been shown to moderate cardio-metabolic disease within a population health context.

Applying an Exposome-Wide (ExWAS) Approach to Cancer Research

Traditional research approaches, including genome-wide association studies (GWAS), epigenome-wide association studies (EWAS) and Gene × Environment (G × E) studies are limited in their ability to handle the multiplicity of chemical and non-chemical toxicants to which people are exposed in the real world, over their life course, their impact on epigenomics and other biological systems, and their relationship to cancer onset, progression, and outcomes. Exposome-wide association study (ExWAS) provides a new approach for conceptualizing the roles and relationships of multiple chemical and non-chemical exposures in the etiology and progression of cancer at key developmental periods, over the life course, and across generations. ExWAS challenges us to consider the influence of both internal and external environment, chemical and non-chemical stressors, risk and protective factors, and spatial and temporal dimensions of exposures in our models of cancer incidence, outcomes, and disparities. Applying an ExWAS approach to cancer and cancer disparities research supports robust computational models and methods that will allow for analysis of the dynamic and complex interactions between genetics, epigenetics, and exposomics factors. In the coming months, we will spatially and temporally align environmental exposures with SCCS participant data from time of enrollment forward to move us closer to identifying complete exposure pathways that lead to cancer. In the future, we hope to link external sources of exposure to biomarkers of exposure, biomarkers of disease, disease phenotypes, and population level disparities.

A novel approach to analyzing lung cancer mortality disparities: Using the exposome and a graph-theoretical toolchain

OBJECTIVES

The aim is to identify exposures associated with lung cancer mortality and mortality disparities by race and gender using an exposome database coupled to a graph theoretical toolchain.

METHODS

Graph theoretical algorithms were employed to extract paracliques from correlation graphs using associations between 2162 environmental exposures and lung cancer mortality rates in 2067 counties, with clique doubling applied to compute an absolute threshold of significance. Factor analysis and multiple linear regressions then were used to analyze differences in exposures associated with lung cancer mortality and mortality disparities by race and gender.

RESULTS

While cigarette consumption was highly correlated with rates of lung cancer mortality for both white men and women, previously unidentified novel exposures were more closely associated with lung cancer mortality and mortality disparities for blacks, particularly black women.

CONCLUSIONS

Exposures beyond smoking moderate lung cancer mortality and mortality disparities by race and gender.

POLICY IMPLICATIONS

An exposome approach and database coupled with scalable combinatorial analytics provides a powerful new approach for analyzing relationships between multiple environmental exposures, pathways and health outcomes. An assessment of multiple exposures is needed to appropriately translate research findings into environmental public health practice and policy.

Validation of research trajectory 1 of an Exposome framework: Exposure to benzo(a)pyrene confers enhanced susceptibility to bacterial infection

The exposome provides a framework for understanding elucidation of an uncharacterized molecular mechanism conferring enhanced susceptibility of macrophage membranes to bacterial infection after exposure to the environmental contaminant benzo(a)pyrene, [B(a)P]. The fundamental requirement in activation of macrophage effector functions is the binding of immunoglobulins to Fc receptors. FcγRIIa (CD32a), a member of the Fc family of immunoreceptors with low affinity for immunoglobulin G, has been reported to bind preferentially to IgG within lipid rafts. Previous research suggested that exposure to B(a)P suppressed macrophage effector functions but the molecular mechanisms remain elusive. The goal of this study was to elucidate the mechanism(s) of B(a)P-exposure induced suppression of macrophage function by examining the resultant effects of exposure-induced insult on CD32-lipid raft interactions in the regulation of IgG binding to CD32. The results demonstrate that exposure of macrophages to B(a)P alters lipid raft integrity by decreasing membrane cholesterol 25% while increasing CD32 into non-lipid raft fractions. This robust diminution in membrane cholesterol and 30% exclusion of CD32 from lipid rafts causes a significant reduction in CD32-mediated IgG binding to suppress essential macrophage effector functions. Such exposures across the lifespan would have the potential to induce immunosuppressive endophenotypes in vulnerable populations.

Using an External Exposome Framework to Examine Pregnancy-Related Morbidities and Mortalities: Implications for Health Disparities Research

Objective: We have conducted a study to assess the role of environment on the burden of maternal morbidities and mortalities among women using an external exposome approach for the purpose of developing targeted public health interventions to decrease disparities. Methods: We identified counties in the 48 contiguous USA where observed low birthweight (LBW) rates were higher than expected during a five-year study period. The identification was conducted using a retrospective space-time analysis scan for statistically significant clusters with high or low rates by a Discrete Poisson Model. Results: We observed statistically significant associations of LBW rate with a set of predictive variables. However, in one of the two spatiotemporal models we discovered LBW to be associated with five predictive variables (teen birth rate, adult obesity, uninsured adults, physically unhealthy days, and percent of adults who smoke) in two counties situated in Alabama after adjusting for location changes. Counties with higher than expected LBW rates were similarly associated with two environmental variables (ozone and fine particulate matter). Conclusions: The county-level predictive measures of LBW offer new insights into spatiotemporal patterns relative to key contributory factors. An external framework provides a promising place-based approach for identifying “hotspots” with implications for designing targeted interventions and control measures to reduce and eliminate health disparities.

Pediatric intensive care unit mortality among Latino children before and after a multilevel health care delivery intervention

IMPORTANCE

Research on health equity has focused on documenting health care disparities or understanding factors leading to disparities, but limited efforts have focused on reducing health care disparities in children. Latino children have increased prevalence of acute and chronic conditions; they have limited access and other barriers to high-quality health care, including intensive care.

OBJECTIVE

To determine whether pediatric intensive care unit mortality can be reduced by a multilevel health care delivery intervention.

DESIGN, SETTING, AND PARTICIPANTS

Observational study of factors associated with pediatric intensive care unit mortality at a tertiary care metropolitan children's hospital in Memphis, Tennessee. Participants were children younger than 18 years discharged from the pediatric intensive care unit during the 3-year preintervention period of 2007 to 2009 (n = 3891) and 3-year postintervention period of 2010 to 2012 (n = 4179).

INTERVENTIONS

Multilevel health care intervention to address the increased odds of mortality among Latino children.

MAIN OUTCOMES AND MEASURES

The odds of mortality were analyzed over the 3-year preintervention period (2007-2009) using multivariable logistic regressions to control for age, sex, race/ethnicity, severity of illness, major diagnostic categories, diagnosed infections, and insurance status. Data from the postintervention period (2010-2012) were analyzed similarly to measure the effect of changes in health care delivery.

RESULTS

Unadjusted mortality rates for white, African American, and Latino children in 2007 to 2009 were 3.3%, 3.3%, and 8.6%, respectively. After controlling for covariates, no differences in the odds of mortality were observed between white children and African American children (odds ratio [OR], 1.0; 95% CI, 0.6-1.7; P = .97), but Latino children had 3.7-fold (95% CI, 1.8-7.5; P < .001) higher odds of mortality. A multilevel and multidisciplinary intervention was launched to address these differences. In the postintervention period, unadjusted mortality rates for white, African American, and Latino children were 3.6%, 3.2%, and 4.0%, respectively, with no differences observed after adjustment for covariates (OR, 0.7; 95% CI, 0.2-2.1; P = .49). The odds of mortality decreased between the preintervention period and postintervention period for Latino children (OR, 0.24; 95% CI, 0.06-0.88; P = .03) but remained unchanged for white and African American children (OR, 1.02; 95% CI, 0.73-1.43; P = .90).

CONCLUSIONS AND RELEVANCE

Latino children had higher odds of mortality, even after controlling for age, sex, severity of illness, insurance status, and other covariates. These differences disappeared after culturally and linguistically sensitive interventions at multiple levels. Local multilevel interventions can reduce the effect of health care inequities on clinical outcomes, without requiring major changes in health care policy.

The public health exposome: a population-based, exposure science approach to health disparities research

The lack of progress in reducing health disparities suggests that new approaches are needed if we are to achieve meaningful, equitable, and lasting reductions. Current scientific paradigms do not adequately capture the complexity of the relationships between environment, personal health and population level disparities. The public health exposome is presented as a universal exposure tracking framework for integrating complex relationships between exogenous and endogenous exposures across the lifespan from conception to death. It uses a social-ecological framework that builds on the exposome paradigm for conceptualizing how exogenous exposures "get under the skin". The public health exposome approach has led our team to develop a taxonomy and bioinformatics infrastructure to integrate health outcomes data with thousands of sources of exogenous exposure, organized in four broad domains: natural, built, social, and policy environments. With the input of a transdisciplinary team, we have borrowed and applied the methods, tools and terms from various disciplines to measure the effects of environmental exposures on personal and population health outcomes and disparities, many of which may not manifest until many years later. As is customary with a paradigm shift, this approach has far reaching implications for research methods and design, analytics, community engagement strategies, and research training.

Scalable combinatorial tools for health disparities research

Despite staggering investments made in unraveling the human genome, current estimates suggest that as much as 90% of the variance in cancer and chronic diseases can be attributed to factors outside an individual’s genetic endowment, particularly to environmental exposures experienced across his or her life course. New analytical approaches are clearly required as investigators turn to complicated systems theory and ecological, place-based and life-history perspectives in order to understand more clearly the relationships between social determinants, environmental exposures and health disparities. While traditional data analysis techniques remain foundational to health disparities research, they are easily overwhelmed by the ever-increasing size and heterogeneity of available data needed to illuminate latent gene x environment interactions. This has prompted the adaptation and application of scalable combinatorial methods, many from genome science research, to the study of population health. Most of these powerful tools are algorithmically sophisticated, highly automated and mathematically abstract. Their utility motivates the main theme of this paper, which is to describe real applications of innovative transdisciplinary models and analyses in an effort to help move the research community closer toward identifying the causal mechanisms and associated environmental contexts underlying health disparities. The public health exposome is used as a contemporary focus for addressing the complex nature of this subject.

Opportunities to address lung cancer disparities among African Americans

Race and socioeconomic status are well known to influence lung cancer incidence and mortality patterns in the U.S. Lung cancer incidence and mortality rates are higher among blacks than whites. In this article we review opportunities to address disparities in lung cancer incidence, mortality, and survivorship among African Americans. First, we summarize recent advances in the early detection and treatment of lung cancer. Then we consider black-white disparities in lung cancer treatment including factors that may contribute to such disparities; the literature on smoking cessation interventions for patients with or without a lung cancer diagnosis; and the important roles played by cultural competency, patient trust in their physician, and health literacy in addressing lung cancer disparities, including the need for culturally competent lung cancer patient navigators. Intervention efforts should focus on providing appropriate quality treatment for lung cancer and educating African Americans about the value of having these treatments in order to reduce these disparities. Culturally competent, patient navigation programs are needed that support lung cancer patients, especially socioeconomically disadvantaged patients, from the point of diagnosis to the initiation and completion of treatment, including cancer staging.

Understanding African American women's decisions to buy and eat dark green leafy vegetables: an application of the reasoned action approach

OBJECTIVE

Examine intentions to buy and eat dark green leafy vegetables (DGLV).

DESIGN

Cross-sectional survey assessing demographics, behavior, intention, and Reasoned Action Approach constructs (attitude, perceived norm, self-efficacy).

SETTING

Marion County, Indiana.

PARTICIPANTS

African American women responsible for buying and preparing household food.

MAIN OUTCOME MEASURE(S)

Reasoned Action Approach constructs explaining intentions to buy and eat DGLV.

ANALYSIS

Summary statistics, Pearson correlations, and multiple regression analyses.

RESULTS

Among participants (n = 410, mean age = 43 y), 76% and 80%, respectively, reported buying and eating DGLV in the past week. Mean consumption was 1.5 cups in the past 3 days. Intentions to buy (r = 0.20, P < .001) and eat (r = 0.23, P < .001) DGLV were positively associated with consumption. Reasoned Action Approach constructs explained 71.2% of the variance in intention to buy, and 60.9% of the variance in intention to eat DGLV. Attitude (β = .63) and self-efficacy (β = .24) related to buying and attitude (β = .60) and self-efficacy (β = .23) related to eating DGLV explained significant amounts of variance in intentions to buy and eat more DGLV. Perceived norm was unrelated to either intention to buy or eat DGLV.

CONCLUSIONS AND IMPLICATIONS

Interventions designed for this population of women should aim to improve DGLV-related attitudes and self-efficacy.

Analysis of an environmental exposure health questionnaire in a metropolitan minority population utilizing logistic regression and Support Vector Machines

The goal of this study was to analyze a 54-item instrument for assessment of perception of exposure to environmental contaminants within the context of the built environment, or exposome. This exposome was defined in five domains to include 1) home and hobby, 2) school, 3) community, 4) occupation, and 5) exposure history. Interviews were conducted with child-bearing-age minority women at Metro Nashville General Hospital at Meharry Medical College. Data were analyzed utilizing DTReg software for Support Vector Machine (SVM) modeling followed by an SPSS package for a logistic regression model. The target (outcome) variable of interest was respondent's residence by ZIP code. The results demonstrate that the rank order of important variables with respect to SVM modeling versus traditional logistic regression models is almost identical. This is the first study documenting that SVM analysis has discriminate power for determination of higher-ordered spatial relationships on an environmental exposure history questionnaire.

Tuskegee redux: evolution of legal mandates for human experimentation

Human health experiments systematically expose people to conditions beyond the boundaries of medical evidence. Such experiments have included legal-medical collaboration, exemplified in the U.S. by the Public Health Service (PHS) Syphilis Study (Tuskegee). That medical experiment was legal, conforming to segregationist protocols and specific legislative authorization which excluded a selected group of African Americans from any medical protection from syphilis. Subsequent corrective action outlawed unethical medical experiments but did not address other forms of collaboration, including PHS submission to laws which may have placed African American women at increased risk from AIDS and breast cancer. Today, anti-lobbying law makes it a felony for PHS workers to openly challenge legally anointed suspension of medical evidence. African Americans and other vulnerable populations may thereby face excess risks-not only from cancer, but also from motor vehicle crashes, firearm assault, end stage renal disease, and other problems-with PHS workers as silent partners.

Cultural competency, human genomics, and the elimination of health disparities

It is unclear what impact human genomics research will have on the nation's efforts to close the gap in health disparities between and among racial/ethnic and disadvantaged groups. The literature suggests that understanding socio-economic and cultural factors are important for understanding the complex issues offer by genetic explanations of racial/ethnic differences. While this research will lead to tremendous improvements in health status of the overall population, its impact on reducing health disparities is likely to be minimal. Establishment of culturally competent systems of care, in contrast, offers great promise for reducing and eliminating health disparities.

100% access, zero health disparities, and GIS: an improved methodology for designating health professions shortage areas

The (Health Professions Shortage Areas) HPSA designation process was developed as a mechanism to identify primary care shortage areas eligible for participation in specific federally funded programs including a 10% Medicare supplement, the National Health Service Corps, and health professions training programs. The purpose of this paper was to explore the utility of Geographic Information Systems (GIS) technology as an improved methodology for obtaining HPSA designation status for geographic areas. Results showed that GIS identified 24 Medical Services Study Areas (rational planning areas) in Los Angeles County that met the minimum 3500:1 population-to-primary-care physician ratio for geographic area HPSA designation compared to only three that currently are identified. Authors concluded that restructuring of the state/county responsibilities for HPSA designation is long overdue and that use of GIS as a required methodology would help ensure that all areas in any state that meet the intent of federal legislation are included.