United States

Background
Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) individuals face higher levels of stress than the general population in the form of minority stress, defined as discriminatory, stigmatizing, and victimizing experiences. Minority stress has been posited as a cause for LGBTQ individuals to smoke as a coping mechanism, leading to higher than average rates of smoking in this population. The Deep South states of Louisiana, Mississippi, Alabama, Georgia, and South Carolina represent an area with both high levels of minority stress and smoking. Therefore, the objective of this study was to elucidate how minority stress influences smoking among LGBTQ smokers in the Deep South, using a mixed methods approach.

Methods
A one-time, cross-sectional online survey was administered to 1,296 LGBTQ smokers in the Deep South. Survey measurements included previously validated measures of minority stress (prejudice events, perceived stigma, and internalized queerphobia), mental health, social support, smoking, quitting, LGBTQ and non-LGBTQ norms, self-efficacy, and smoking outcome variables (stage of change and nicotine dependence level). Multiple linear regression was used to assess the relationship between minority stress variables and smoking outcome variables. To expound on how minority stress affects mental health and subsequent stage of change, 15 individual, semi-structured online interviews were conducted with LGBTQ smokers in the Deep South. Interview topics spanned across 5 domains: LGBTQ identity, smoking/quitting, minority stress, mental health, and social support.

Results
Survey findings showed that after adjusting for covariates, increased levels of internalized queerphobia were significantly associated with increased nicotine dependence level, and decreased levels of perceived stigma were associated with further stage of change. Six themes emerged across interviews: struggles with LGBTQ identity, coping with minority stress, reasons for smoking, desire to quit smoking, and barriers to quitting smoking.

Conclusion
This study elucidates how increased levels of minority stress are associated with poorer smoking outcomes among LGBTQ individuals in the Deep South. Findings will help guide future smoking prevention and cessation programs for LGBTQ smokers. Addressing minority stress in future targeted smoking interventions has the potential to reducing smoking disparities in LGBTQ populations.

AMA Research Challenge 2023

Minority Stress among LGBTQ Smokers in the Deep South: A Mixed Methods Study

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Background:
Historical redlining, a discriminatory practice that denied mortgage loans to people of color based on perceived risk, has had lasting effects on communities. These redlined areas, marked as high-risk on maps, continue to face health disparities. This study investigates the relationship between redlining and all-cause mortality rates in Austin, Texas.


90 Years Later: How Historical Redlining Predicts All-Cause Mortality in Austin, Texas

Background
Louisiana's Hispanic/Latinx population is a diverse community that has experienced significant growth in recent years. Unfortunately, COVID-19 has disproportionately impacted racial and ethnic minority groups, including Hispanics/Latinx, who often face disparities in healthcare access and outcomes. This study aims to investigate the impact and potential disparities of COVID-19 infection among the Hispanic/Latinx community in Northwest Louisiana.

Methods
A cross-sectional survey was conducted between June 2022 and March 2023. A total of 242 participants were recruited and asked to complete a structured questionnaire. Eligible participants included individuals above 18 years old who identified as Hispanic or Latinx and resided in Northwest Louisiana. Data analysis was conducted using SPSS Version 28 with a statistical significance level set at p < 0.05. Descriptive statistics were utilized to summarize and compare the characteristics of the overall sample, while Pearson’s Chi-squared tests were used to identify risk factors.

Results
The average age of the participants was 42.2 years, 64.7% were female, 56.6% were born in Mexico, 37.7% had attained high school education, 54.1% did not speak English, 61.3% were married, and 51.1% were below the poverty level. Approximately 80% of the study participants had access to COVID-19 testing, with 44.3% receiving testing in a clinical or hospital setting. Among the study participants, 53.6% had been infected with COVID-19. Of those infected, more than half (50.4%) did not receive medical care from a clinic or hospital. Additionally, 63.9% personally knew someone who had suffered severe illness due to COVID-19, and 68% expressed concern about contracting the virus. Factors associated with increased risk of COVID-19 infection included being female, having limited English proficiency, living with 3 or more people, obesity, and asthma.

Conclusion
This cross-sectional survey offers insights into the impact and disparities experienced by the Hispanic/Latinx population in Northwest Louisiana during the COVID-19 pandemic. These findings can aid in implementing prevention measures, resource allocation, and targeted interventions to reduce the risk of COVID-19 and other infectious diseases among minority communities, particularly Hispanics/Latinx.

Disparities and risk factors of COVID-19 infection among Hispanic/Latinx in northwest Louisiana: A Cross-Sectional Study

Background:
Firearm violence is increasingly prevalent in the United States. As such, the number of people living with retained bullet fragments (RBFs) is rising. Lead toxicity is a rare, but known complication of living with an RBF. Lead is a teratogen and fetal exposure to lead has been linked to a variety of congenital abnormalities and cognitive development impairment. Little is known about the risk of maternal-fetal lead toxicity from RBFs. The purpose of this dual systematic review is to investigate the impact that RBFs may have on pregnant patients and their fetuses.
Methods:
Two systematic reviews were conducted, adhering to PRISMA guidelines, using
PubMed/MEDLINE and Embase: one explored the relationship between lead poisoning and retained bullet fragments/foreign bodies, and the second examined the relationship between prenatal lead exposure and fetal/child development. The quality of each included study was assessed on a scale of 0 to 5.
Results:
Of the 494 search results of the first review, only 5 (average quality: 4.2) explored the relationship between retained bullet fragments and blood lead levels, all of which demonstrated a strong association. Of the 753 search results of the second review, 11 (average quality of 3.91) examined the relationship between elevated maternal BLL and fetal development, and all highlighted that elevated maternal BLL is associated with neurobehavioral, cognitive, and cardiovascular fetal development.
Conclusions:
Retained bullet fragments may be a risk factor for lead toxicity in pregnant people with the potential for detrimental effects on the pregnancy and fetus. These patients should be educated about the risk and screened for lead levels during pregnancy. To further improve the health outcomes of this subpopulation and to determine the most appropriate treatment options, more research is needed.

Considering Lead Levels in Pregnancy-Capable People with Retained Bullet Fragments

Background: As diversity continues to flourish in the United States (US), more patients encountered by physicians primarily speak languages other than English. 25.5 million people in the US disclosed they were Limited English Proficient (LEP). LEP patients are known to be marginalized in terms of receiving adequate health care and undergo less preventative care than other individuals of the same ethnicity that are proficient in English. 

Objective: To determine the prevalence and risk factors of breast and cervical cancer screening rates between women with and without difficulty communicating. 

Methods: A retrospective analysis was conducted of adult women using the 2021 National Health Interview Survey. The rates of breast and cervical cancer screening between women who indicated they had “difficulty communicating” to women who did not were compared. The US Preventive Screening Task Force guidelines were used. Demographic and behavioral variables were analyzed in relation to reported breast and cervical cancer screening. SAS v9.4 was used to analyze the data in a manner that accounts for the complex sample survey design. Bivariate comparisons were performed using Chi-square test, all significance tests were two-sided, p-value < .05 for significance. This study was approved by UND IRB. 

Results: Of the estimated 50 million (unweighted n=6,851) respondents, 4.2% of women reported having difficulty communicating. Women who reported having difficulty communicating were significantly less likely to have received a mammogram within the last 2 years than women who reported no difficulty communicating (p=.015). Similarly, women who reported having difficulty communicating were significantly less likely to have ever had cervical cancer screening (p=.000), to have the last visit as wellness visit (p=.014), and to report poor health (p=.000) than women who reported no difficulty communicating. There was no association between being a US citizen, duration in the US, or birth in the US and difficulty communicating. 

Conclusion: Women with difficulty communicating were less likely to report mammography and cervical cancer screening compared to those with no difficulty communicating. Physicians should spend longer visits with women who have difficulty communicating to enhance preventive cancer screenings and should encourage yearly wellness visits.

Association Between Difficulty Communicating and Breast and Cervical Cancer Screening

Background
Nearly 38.3 million people are food-insecure nationwide. Food insecurity has been associated with diabetes, hypertension, obesity, arthritis, asthma, and decreased mental health. Despite food insecurity, nearly 35% of all grown food goes unsold or unconsumed, equating to around 130 billion meals and up to $285 billion in annual losses. Redistribution programs can alleviate hunger and provide tax benefits to donors. This study sought to investigate the challenges and successes of Brown County, Wisconsin food sectors regarding food waste, redistribution, and salvaging. Educational resources were provided to interested donors.

Methods
Electronic surveys were distributed via email or social media to 479 potential donors, including K-12 schools, colleges, restaurants, and more. Data was collected and analyzed via Qualtrics.

Results
Results (n=31) showed that although most donors expressed food sustainability concerns, a large number have no or low familiarity with food redistribution and salvaging. Further, greater than 50% of donors do have reduction efforts in place; however, only 40% have efforts specific to redistribution. On average, 5.84% of inventory goes unused each month; prepared foods comprise 50.29% of disposed foods, followed by baked goods and fresh produce each at ~15%. Finally, only 23% and 35% of potential donors expressed knowledge of tax benefits and legal protections, respectively.

Conclusion
Although statistical significance was not attained, this study demonstrated great potential for donors to alter food practices, providing donations to those in need. Additionally, there are significant opportunities for education on redistribution logistics and benefits. Future directions include outreach to additional donors, dissemination of information on tax advantages and legal protections, and small-scale pilot studies.

Food Salvaging and Redistribution in Brown County, Wisconsin

Over 40% of U.S. adults disclosed delaying both urgent and routine medical care during the pandemic due to COVID-19 concerns. We aimed to examine impacts of delays in care through the development of new chronic conditions since the beginning of the pandemic. For this cohort of older adults who lived through the COVID-19 pandemic, prevalence of all chronic conditions rose in age-stratified analyses, indicating worsening population health. However, delays in medical care during the pandemic were not associated with chronic condition development. Delays in care may have been compensated for by telehealth, medication delivery, and other services specific to the pandemic.

Impact of reported delay in medical care during the COVID-19 pandemic on development of chronic conditions in U.S. older adults

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

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

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

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



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

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

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

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

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


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

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

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

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

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

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

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

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

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

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Next from AMA Research Challenge 2023

90 Years Later: How Historical Redlining Predicts All-Cause Mortality in Austin, Texas