United States

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

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

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

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

AMA Research Challenge 2024 

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

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

Racial and Ethnic Diversity in the US Ophthalmology Clinical Trials

Background 
Cardiovascular disease significantly impacts life expectancy and quality of life, and is responsible for the highest number of deaths in Albania, comprising 59% of all mortality cases. However, limited data exists on the influence of social determinants of health on the prevalence of cardiovascular disease in Albania. This study aims to fill the gaps in the available literature by analyzing associations between socio-economic determinants of health and cardiovascular disease prevalence to guide public health interventions in Albania.

Methods: This cross-sectional study used secondary data from the Albania Demographic and Health Survey of 2017-2018. This comprehensive survey was conducted on sample clusters proportional to each county’s population size, with 17,160 households overall. There were 15,000 women and 6,142 men successfully interviewed. SPSS and Python performed statistical analysis utilizing chi-square tests to explore the associations between the social determinants and cardiovascular disease prevalence. 

Results: 
The findings showed a significant difference (p <0.05) in cardiovascular disease prevalence between different income and education levels. The results were similar among males and females. There were no significant differences in the prevalence of cardiovascular disease in different geographic residences (p>0.05). 

Conclusion: The study findings indicate that social determinants of health may play a role in cardiovascular disease prevalence in Albania, aligning with global research that describes social determinants as critical factors in cardiovascular health. It emphasizes the need for targeted public health interventions and calls for an increase in future research to effectively identify and address economic and educational social determinants associated with cardiovascular disease in Albania. Limitations of the study include its reliance on cross-sectional data, underreporting or self-reporting bias, and the potential changes in the health of the Albanian population since the 2017 health survey.

Role of Social Determinants of Health in the 
Prevalence of Cardiovascular Disease in Albania.


Sociodemographic Profile of Depression in High School Students in Cochabamba: A Subnational Study

Background: The study aims to analyze the association between sociodemographic characteristics and the presence of depression in high school students in the city of Cochabamba. Understanding these associations is crucial for developing targeted interventions to address mental health issues among adolescents. As identified in previous studies, these factors were chosen based on their potential influence on mental health.

Methods: An observational analytical cross-sectional study was conducted involving 41,820 high school students who completed a survey based on the Beck Depression Inventory Type I. Statistical analysis included frequency distributions and 95% confidence intervals. The risk of depression was analyzed using crude and adjusted odds ratios (OR).

Results: Among the participants, 52.8% were female. At the time of data collection, 11.7% had severe depression, 9.1% had moderate depression, and 7.1% had mild depression. Males had a lower risk of experiencing any degree of depression (OR: 0.91). Age groups 15-18 years (OR: 0.78) and 19-22 years (OR: 0.80) had a lower risk compared to the 11-14 years age group. Those who spoke Spanish and Quechua had a lower risk than those who spoke Aymara (OR: 0.51 and OR: 0.91, respectively). Adolescents from the Southern Cone showed a higher risk (OR: 1.35) compared to other locations, and those with health insurance had a lower risk (OR: 0.94).

Conclusion: The prevalence of depression among adolescents in Cochabamba was 27.9%. Significant risk factors included being female, aged 11-14 years, of indigenous ethnicity, lacking health insurance, and residing in the Southern Cone. These findings suggest the need for tailored mental health interventions that focus on these high-risk groups. Implementing targeted screening programs in schools, providing culturally sensitive mental health services, and improving access to health insurance could be effective strategies to mitigate these risk factors.

Sociodemographic Profile of Depression in Secondary School Students in Cochabamba: A Subnational Study

Background: Wildfire severity and frequency have increased in the last two decades, as have their consequences and public attention toward these disasters. Wildfires have led to community evacuations, social disruptions, significant property damage, loss of life, and impacts on economic activity in communities across California. However, the effect of fires on individual healthcare facilities and the health system has received comparatively less attention. There is a lack of empirical assessments on how this risk affects the operations of healthcare facilities and the spatial trends of actual wildfire exposure. We use historical wildfire perimeter data, and inpatient healthcare facility data to assess trends by county in observed exposure to wildfire between 2001 and 2023 in California.

Methods: Inpatient facility data was collated from the California State Department of Health Care Access and Information. Data on annual wildfire perimeters was retrieved from the California Department of Forestry and Fire Protection. Inpatient facility data from the pre-2008 era did not include geospatial coordinates for facility locations. However, they included street address data which was geocoded using a Google Maps API in R, and supplemented with manual geocoding. The ‘sf’ package in R was then used to compute the nearest distance to a wildfire perimeter each year for each licensed and open facility (closed facilities were excluded from analysis). The proportion of facilities that were within ten miles of a wildfire perimeter were summarized, by year, and by county. 

Results: Between 2001 and 2023, 20 of California’s 58 counties had at least an average of 50% of inpatient facilities within ten miles of a wildfire perimeter. For three counties, Placer, Shasta, and Ventura, more than 75% of inpatient facilities experienced wildfires within ten miles of the facility site between 2001 and 2023. While all but two counties experienced a wildfire within ten miles of an inpatient facility at some point, the frequency of wildfires near inpatient facilities is not evenly distributed across the state. 

Conclusion: Addressing the threat to healthcare facilities will require action at multiple scales. Policies to address the root causes of the increase in wildfire exposure are essential; these may include policies directed at reducing wildfire ignition, improving land-use management, guiding future development decisions, and mitigating future climate change through reductions in fossil fuel use and greenhouse gas emissions. Empirical data such as the results of this study may help prioritize wildfire adaptation investments for healthcare facilities in specific California counties.



Spatial Variability of Wildfires and Inpatient Healthcare Facilities in California Counties

Background: With 8.4% of Americans uninsured, free clinics act as safety nets for those without healthcare access. The CommunityCare Clinics (CCC) operate student-run free clinics in Toledo, Ohio. This study compared the demographics of patients served within these clinics to the city’s census data to analyze health needs, barriers to care, and characteristics of the underserved population.

Methods: This retrospective survey reviewed 1,338 visits at five clinic sites from February 2023- February 2024. Parameters included race, insurance, education, sex, health insurance status, and primary language. Comparative analysis was completed using 2020 Census data for Toledo, OH.

Results: Significant differences were found between the demographic characteristics of those served in the clinic population and the population of Toledo. The clinic served 22.63% fewer White patients, 17.27% more Hispanic/Latino patients, and 5.62% fewer African American patients than the city population. Among patients under 65 years, 61.91% were uninsured compared to 8.3% in Toledo. Fewer English speakers (66.60% vs. 93.2%) and more Spanish speakers (21.72% vs. 3.2%) were treated. The clinic had slightly fewer high school graduates (82.97% vs. 87.10%) but more higher education recipients (27.10% vs. 19.6%). 

Conclusions: This study highlights the demographic differences between the clinic and the city, helping identify those benefiting from these services. The inconsistency in patient demographics across free clinics in the United States should be considered by policymakers and public health agencies.


The Demographic Gap: A Comparative Analysis of the Demographics of Free Clinic Patients With the City Served

COVID-19 disproportionately affected under-resourced communities. In response, the Unified Government Public Health Department (UGPHD) integrated a social needs screening into its Contact Tracing Investigation (CTI) program. This study aims to describe this approach, identify community needs, and analyze factors associated with specific social needs. Volunteers from the CTI program contacted Wyandotte County, Kansas residents who tested positive for COVID-19 to conduct both contact tracing and assess social needs. Key areas of need included food, workplace documentation, behavioral health support, federal assistance eligibility, and community health worker (CHWs) referral. The CTI program connected community members to 4,400+ resources. Non-English speakers and residents in high-deprivation areas requested food, work release letters, and federal aid more frequently. Requests for CHWs were common among those identifying as non-White, requiring interpreters, or unemployed. The UGPHD's CTI program successfully linked residents to essential social services, highlighting the value of public health departments in supporting underserved communities.

The Disease Investigation Process: A Vehicle for Social Services

Background
Fostering cultural competence in medical education and healthcare settings is crucial for treating diverse patient populations. Middle Eastern North African (MENA)-Americans are categorized as White in the U.S. racial categorization, however, their health needs and experiences drastically. To provide culturally appropriate care, there is a need for disaggregated data on the 3.5 million MENA-Americans from White individuals. This literature view aims to highlight the techniques and strategies to advance MENA health, patient education, and cultural competence among healthcare.
Methods
A comprehensive search using keywords like “MENA,” “Middle Eastern,” “North African,” “health outcomes,” “patient outcomes,” “minority health,” and “medical education” was conducted in PubMed, This yielded 216 papers for consideration. Inclusion criteria focused on studies related to MENA-American health, medical education on MENA health, and culturally competent care for MENA-American individuals. After abstract screening, 90 papers were selected for full-text review, with 22 meeting the inclusion criteria. 
Results
All 22 articles highlight the need for increased cultural education of this minority group, with key cultural factors identified include language and communication (n=9), family and community involvement (n=12), religious practices and dietary needs (n=9), cultural education (n=8), and stigma (n=5). 10 studies highlight the need for integration of traditional cultural practices into healthcare interventions. Only three intervention studies were identified, which included health education classes (n=2) and online interactive patient simulations (n=1). Eighteen studies offered recommendations for potential future health interventions, including culturally tailored prevention programs, recruitment of Arabic-speaking providers, and implementation of cultural training modules.
Conclusion
This literature review highlights the importance of tailored efforts to improve MENA health, patient and medical education, and cultural competence in healthcare settings. Although research on MENA-American health is limited, there is a growing understanding of the cultural considerations necessary for caring for this community. It is vital to move towards implementing interventions to fill in the gaps that have been highlighted in the literature. Doing so will enhance cultural competence and ultimately improve the care that MENA-Americans receive.


The Need for Cultural Competence in Serving the MENA-American Community​

Introduction: 

Most Americans now live in states that have a medical marijuana dispensary. Increases in the number of patients enrolled in medical marijuana programs nationally between 2016 and 2020 parallel a steady increase in the number of qualifying conditions (QC) with limited to no evidence. Like other states, Pennsylvania’s medical marijuana program has experienced rapid expansion since its inception in 2017, with the number of enrolled patients surging from 1,230 in 2017 to 432,717 in 2023. 

Research Question: 

To what extent were certifications in the Pennsylvania medical marijuana (MMJ) program evidence-based? 

Methods: 

QCs, zip-codes, and certification dates for each MMJ patient from 2017-2023 were obtained from the Pennsylvania Department of Health and the US Census Bureau's Population Estimates Program (PEP) datasets. Using the NAS 2017 report, Pennsylvania’s 21 QCs were categorized as either evidence-based (substantial to conclusive evidence) or not evidence-based (limited to no evidence). 

Results: 

In 2017, 67.6% of enrolled MMJ patients had at least one evidence-based condition. Following the addition of anxiety disorders as a QC in 2019, we observed a continuous decline in the share of evidence-based certifications. In 2023, 41.1% of patients had at least one evidence-based QC. From 2017-2019, the most common patient was certified for only chronic pain (37.3%-46.5%). From 2020-2023, patients having only anxiety disorders were the most common MMJ patient (31.7%-43.5%). 

Conclusion: 

The decrease in the proportion of evidence-based MMJ certifications from 2019-2023 indicates that national patterns between 2016-2020 extend into 2023 for the Pennsylvania MMJ program. Given that evidence-based medicine is the gold standard, there is a need for further research into the impacts of marijuana on anxiety disorders, for lawmakers to re-evaluate QCs, and for providers to more rigorously make MMJ certifications. 



The Pennsylvania Paradox: Medical Marijuana’s Rapid Growth Amidst Evidence-Based Uncertainty from 2017- 2023 ​​

Trends in Cannabis Use and Associated Volatile Organic Compounds: Implications for Public Health Policy
Andrew Goulian MPH, Brielle Goldstein, David Bell MD, MPH
California Northstate University College of Medicine, Elk Grove, CA
Mailman School of Public Health Columbia University, New York, NY

Background
The legalization of cannabis has increased its accessibility and use across the United States, raising concerns about public health. This study investigates the trends in cannabis use from 2009 to 2018 and examines the association with volatile organic compounds (VOCs) such as benzene and ethylbenzene, which are found in cannabis smoke. The objective is to understand the impact of these trends on public health and policy.

Methods
Data on cannabis use were obtained from the National Health and Nutrition Examination Survey (NHANES) from 2009 to 2018, including a total of 8,912 participants. These data were merged with demographic variables (gender, age, race/ethnicity, education level, household income) and blood levels of VOCs (benzene and ethylbenzene). A survey-weighted logistic regression model was used to examine the associations between cannabis use and these variables. Time-series analysis was conducted to observe trends over the decade.

Results
The logistic regression model showed significant associations between cannabis use and several variables. Males had lower odds of cannabis use compared to females (p<0.001). Higher education levels were associated with higher odds of cannabis use (p<0.001), and higher household income was associated with lower odds of cannabis use (p<0.05). Blood levels of benzene were significantly associated with higher odds of cannabis use (p<0.001), while blood levels of ethylbenzene were associated with lower odds of cannabis use (p<0.001). Over the decade of analysis, the number of states that legalized recreational cannabis increased from 0 to 10, reflecting a broader trend of increased cannabis accessibility.

Conclusion and Impact
The findings highlight significant demographic and chemical exposure factors associated with cannabis use. The increase in cannabis legalization and its associated VOC exposure pose potential public health risks. Public health policies should address the implications of increased cannabis use and associated VOC exposure, particularly focusing on preventive measures and education to mitigate these risks. The study underscores the need for ongoing surveillance and research to inform evidence-based public health strategies in the context of evolving cannabis legislation. This research is critical for informing policymakers on the health risks of cannabis-related VOC exposure and could shape future regulations to promote health equity and safer cannabis consumption.


Trends in Cannabis Use and Associated Volatile Organic Compounds: Implications for Public Health Policy

Nearly 30% of the population of Guam relies on the local Medicaid program for healthcare coverage. Due to a high prevalence of non-communicable disease, access to affordable chronic care management is crucial to sustaining the island territory’s healthcare system. With nearly $130 million in federal match funding, understanding the spending trends of Guam’s Medicaid program may yield insight to how these funds are being accessed by the patient population. Data was obtained from the Medicaid section of the Medicaid and MIP Expenditure and Demographic End of 4th Quarter Report available on the Guam Department of Health and Human Services Bureau of Health Care Financing Administration web page. A data set was constructed from reports published for fiscal years 2014-2023. Categories for expenditure were titled “Type of Service” on the report and all services provided in the report were included in the data set. Regression analysis was performed to determine average change in expenses over time. Between 2014 and 2023, total expenses increased from $57.9 million to $115.3 million (R2=0.84). 16 out of 24 services had an average increase in expenses. Amongst services, the greatest average increase was observed in Inpatient Hospital services with $6,601,156 (p=0.00005; R2=0.8). The greatest average annual decrease was observed in Dental services with -$897,347 (p=0.003; R2=0.6) Increases in Emergency Room services (p=0.004; R2=0.6), Outpatient Hospital services (p=0.001; R2=0.8), and Home Health services (p=0.02; R2=0.7) were also observed. No statistically significant increase was seen in FQHC with an annual average decrease of -$75,170 (p=0.2; R2=0.1) Although there has been a dramatic increase in total spending by the Guam Medicaid program, there is disparity in how this increase has been distributed across available services. Between 2014 and 2023, there have been increases in spending observed in Hospital services (Inpatient, Outpatient, and Emergency Room) with no increase in spending for primary care services (FQHC) during this time of overall spending growth. Publicly funded Dental services have observed dramatically decreased reimbursement. Information regarding disease prevalence and healthcare infrastructure must be considered to fully contextualize these findings. Local and federal policy makers should acknowledge these trends and ensure that distribution of the territorial Medicaid resources aligns with the needs of the island community.

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