United States

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 &lt; .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.

AMA Research Challenge 2023

Association Between Difficulty Communicating and Breast and Cervical Cancer Screening

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.

poster

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Join the AMA Research Challenge poster symposium and semifinals to explore top research posters, score posters in the semifinals (an AMA member exclusive opportunity) and attend education sessions with experienced physicians to learn tips to advance your research and career. 

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.

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

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

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

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

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

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

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

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

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


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

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

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


Next from AMA Research Challenge 2023

Food Salvaging and Redistribution in Brown County, Wisconsin