Barriers and proposed solutions to at-home colorectal cancer screening tests in medically underserved health centers across three US regions to inform a randomized trial.

INTRODUCTION: At-home colorectal cancer (CRC) screening is an effective way to reduce CRC mortality, but screening rates in medically underserved groups are low. To plan the implementation of a pragmatic randomized trial comparing two population-based outreach approaches, we conducted qualitative research on current processes and barriers to at-home CRC screening in 10 community health centers (CHCs) that serve medically underserved groups, four each in Massachusetts and California, and two tribal facilities in South Dakota. METHODS: We conducted 53 semi-structured interviews with clinical and administrative staff at the participating CHCs. Participants were asked about CRC screening processes, categorized into eight domains: patient identification, outreach, risk assessment, fecal immunochemical test (FIT) workflows, FIT-DNA (i.e., Cologuard) workflows, referral for a follow-up colonoscopy, patient navigation, and educational materials. Transcripts were analyzed using a Rapid Qualitative Analysis approach. A matrix was used to organize and summarize the data into four sub-themes: current process, barriers, facilitators, and solutions to adapt materials for the intervention. RESULTS: Each site's process for stool-based CRC screening varied slightly. Interviewees identified the importance of offering educational materials in English and Spanish, using text messages to remind patients to return kits, adapting materials to address health literacy needs so patients can access instructions in writing, pictures, or video, creating mailed workflows integrated with a tracking system, and offering patient navigation to colonoscopy for patients with an abnormal result. CONCLUSION: Proposed solutions across the three regions will inform a multilevel intervention in a pragmatic trial to increase CRC screening uptake in CHCs.

Trends in HPV-associated cancer incidence in Texas medically underserved regions.

BACKGROUND: While cervical cancer incidence rates (IR) in the United States have dropped in the last 20 years, non-cervical human papillomavirus (HPV) associated cancers increased. Many people in Texas (TX) live in medically underserved areas and have higher risk of developing HPV-associated cancers. Since previous studies of these regions focused on cervical cancer, we included other HPV-associated cancers in our analysis of IR in East TX and the TX-Mexico Border compared to other TX regions. METHODS: Cancer data from 2006 to 2019 were obtained from the TX Cancer Registry. Cases of HPV-associated cervical, vaginal, vulvar, penile, anal, and oropharyngeal cancers and corresponding patient-level demographic data were included. We calculated IR per 100,000 and drew heat maps to visualize cancer IR by county. To control potential confounders, we added county-level risk factors: rates for smoking, excessive drinking, obesity, STIs, primary care provider availability and dentist availability, from the County Health Rankings and Roadmaps program. We reported IRs by region and time and estimated unadjusted and adjusted risk ratio (RR) for association of each type of cancer and region. Lastly, we created adjusted models for each cancer by period to see time trends of regional differences. RESULTS: Risk of anal, cervical, and oropharyngeal cancer was lower at parts of the Border than in the rest of TX in the adjusted model. We also observed increasing anal and oropharyngeal cancer risk and decreasing cervical and vaginal cancer risk over time. CONCLUSION: Patient sociodemographics, behavioral risk factors, and access to care may contribute to some observed differences in cancer IR across regions. This indicates that targeted prevention efforts towards these regions, especially in low socioeconomic status communities, may benefit future generations.

Practice outcomes for the first decade of Rural Pharmacy Education (RPHARM) Program graduates.

BACKGROUND: The maldistribution of pharmacy services in underserved areas is a national issue. Analysis of data from the 2019 National Pharmacist Workforce Study indicated that 13.9% of pharmacists were working in a rural community. However, the percentage of people living in rural communities in the United States is 20.0%. Currently, there are 20 rural pharmacy programs in the United States, including the Rural Pharmacy Education (RPHARM) Program at University of Illinois Chicago (UIC) College of Pharmacy, which contain both didactic and experiential rural components. This research project examines the practice outcomes of the RPHARM Program graduates. METHODS: Descriptive analysis was used to examine the practice outcome characteristics of RPHARM Program graduates between 2014 and 2023. The characteristics of the RPHARM graduates included the rurality of hometowns, practice locations and populations, and distance of practice locations to hometowns. Rural practice outcomes were described utilizing frequently used rural definitions. The practice locations of 54 of the 61 RPHARM graduates were used in the analysis. RESULTS: Approximately 41% of the practicing RPHARM graduates were from rural hometowns and two-thirds were female. RPHARM graduates mostly work in either a community setting (44.4%) or a hospital setting (37.0%). Approximately 11% worked in a federal government organization and 5.6% worked in a long-term care pharmacy. When examining job location, 42.6% were working in a rural location based on Rural-Urban Commuting Area Version 3.0 and 35.2% of RPHARM graduates had always worked in a rural location. Approximately 57% of practicing RPHARM graduates are working in a location < 50 miles from their hometown, and 13% are working 50 to 100 miles from their hometown. Approximately 74% of RPHARM graduates are practicing in Illinois. CONCLUSIONS: Approximately 40% of RPHARM graduates practice in rural locations. A significant portion (35.2%) of RPHARM graduates have always practiced in rural locations, and many (57.4%) are practicing near their hometowns. Results indicate that the RPHARM Program is making meaningful contributions to increasing the rural pharmacy workforce. Due to the lack of information on rural pharmacy practice outcomes, all programs with rural pharmacy content are encouraged to track graduates' practice locations.

Assessing maternity care access: impacts on cesarean sections and dystocia.

BACKGROUND: As South Korea grapples with a declining birthrate, maternity care accessibility has become challenging. This study examines the association with labour intervention and pregnancy complication, specifically focusing on C-section and dystocia in maternity disparities. METHODS: Data from the South Korean NHIS-NID was used to analyze 1,437,186 women with childbirths between 2010 and 2015. The research defines 50 specific districts as Obstetrically Underserved Areas produced by the Ministry of Health and Welfare in 2011. C-Section were assessed through using medical procedure and DRG codes, while dystocia was defined using ICD-10 code. Logistic regression analysis was used to examine the significance of the association. RESULTS: Among the population residing in underserved areas, 42,873 out of a total of 1,437,186 individuals were identified. For nationwide cases, the odds ratios (ORs) for C-Section were 1.11 (95% CI: 1.08-1.13) and dystocia were 1.07 (95% CI: 1.05-1.09). In relatively accessible urban areas, the ORs for C-Section and dystocia, based on whether they were obstetrically underserved areas, were 1.16 (95% CI: 1.13-1.18) and 1.10 (95% CI: 1.08-1.19), respectively. CONCLUSION: Poor accessibility to maternity care facilities is closely linked to high-risk pregnancies, including an increased incidence of dystocia and a higher rate of C-sections. Insufficient access to maternity care not only raises the risk of serious pregnancy complications. Consequently, there is a pressing need for multi-faceted efforts to bridge this disparity.

Novel High-tech, Low-cost Ventilation for Military Use, Mass Casualty Incidents, Stockpiling, and Underserved Communities.

INTRODUCTION: Despite the significant need for mechanical ventilation in- and out-of-hospital, mechanical ventilators remain inaccessible in many instances because of cost or size constraints. Mechanical ventilation is especially critical in trauma scenarios, but the impractical size and weight of standard mechanical ventilators restrict first responders from carrying them in medical aid bags, leading to reliance on imprecise manual bag-mask ventilation. This is particularly important in combat-related injury, where airway compromise and respiratory failure are leading causes of preventable death, but medics are left without necessary mechanical ventilation. To address the serious gaps in mechanical ventilation accessibility, we are developing an Autonomous, Modular, and Portable Ventilation platform (AMP-Vent) suitable for austere environments, prolonged critical care, surgical applications, mass casualty incidents, and stockpiling. The core system is remarkably compact, weighing <2.3 kg, and can fit inside a shoebox (23.4 cm × 17.8 cm × 10.7 cm). Notably, this device is 65% lighter than standard transport ventilators and astoundingly 96% lighter than typical intensive care unit ventilators. Beyond its exceptional portability, AMP-Vent can be manufactured at less than one-tenth the cost of conventional ventilators. Despite its reduced size and cost, the system's functionality is uncompromised. The core system is equipped with closed-loop sensors and advanced modes of ventilation (pressure-control, volume-control, and synchronized intermittent mandatory ventilation), enabling quality care in a portable form factor. The current prototype has undergone preliminary preclinical testing and optimization through trials using a breathing simulator (ASL 5000) and in a large animal model (swine). This report aims to introduce a novel ventilation system and substantiate its promising performance through evidence gathered from preclinical studies. MATERIALS AND METHODS: Lung simulator testing was performed using the ASL 5000, in accordance with table 201.105 "pressure-control inflation-type testing" from ISO 80601-2-12:2020. Following simulations, AMP-Vent was tested in healthy 10-kg female domestic piglets. The Children's Hospital of Philadelphia Institutional Animal Care and Use Committee approved all animal procedures. Swine received 4-min blocks of alternating ventilation, where AMP-Vent and a conventional anesthesia ventilator (GE AISYS CS2) were used to titrate to varied end-tidal carbon dioxide (EtCO2) goals with the initial ventilator switching for each ascending target (35, 40, 45, 50, 55 mmHg). RESULTS: During ASL 5000 simulations, AMP-Vent exhibited consistent performance under varied conditions, maintaining a coefficient of variation of 2% or less within each test. In a large animal study, AMP-Vent maintained EtCO2 and SpO2 targets with comparable performance to a conventional anesthesia ventilator (GE AISYS CS2). Furthermore, the comparison of minute ventilation (Ve) distributions between the conventional anesthesia ventilator and AMP-Vent at several EtCO2 goals (35, 40, 45, 50, and 55 mmHg) revealed no statistically significant differences (p = 0.46 using the Kruskal-Wallis rank sum test). CONCLUSIONS: Preclinical results from this study highlight AMP-Vent's core functionality and consistent performance across varied scenarios. AMP-Vent sets a benchmark for portability with its remarkably compact design, positioning it to revolutionize trauma care in previously inaccessible medical scenarios.

Engagement in rapid public health research among young people from underserved communities: maximising opportunities and overcoming barriers.

BACKGROUND: Inclusion in public health research of young people from low-income households and those from minority ethnic groups remains low. It is recognised that there is a need to change the way in which research is conducted so that it becomes more inclusive. The aim of this work was to identify novel and innovative ways to maximise recruitment and inclusion of diverse participants when doing co-production within very short time frames for emergency responses. METHOD: We conducted interviews with young people from low-income and minority ethnic backgrounds, and members or leaders of groups or organisations supporting or representing young people from underserved communities. RESULTS: A total of 42 participants took part in an interview. This included 30 young people from low income or minority ethnic backgrounds and 12 community leaders/service providers. Of the 30 young people, 26 participants identified as female and 12 participants identified as being from a minority ethnic background. Participants discussed a number of interrelated barriers to research involvement and identified ways in which barriers may be reduced. Prejudice and discrimination experienced by young people from underserved communities has led to substantial mistrust of educational and governmental establishments. Rigid and unfamiliar research practices further limit the involvement of young people. Four themes were identified as ways of supporting involvement, including: making opportunities available for young people, adaptations to research governance, understanding and acknowledging challenges faced by young people, and ensuring reciprocal benefits. CONCLUSION: This research explored barriers to engagement in rapid public health co-production. Working with communities to co-produce rapid recruitment and research procedures to suit the needs and the context in which young people live is necessary.

Infertility care in an underserved population: A retrospective chart review of a resident-run clinic at an urban, public hospital.

Despite major advances in infertility services, barriers to care as well as disparities in outcomes remain a significant problem. The cost of treatment, lack of or inadequate coverage, and location of infertility clinics are obvious contributors, however, advanced pathology, coexistent medical conditions, and lack of preconception care also contribute to delay in fertility particularly in underserved communities. Previous studies have discussed the role of trainee-run clinics in lower socioeconomic populations in providing low-cost infertility evaluation and management. This study uses a retrospective chart review to compare the etiology and duration of infertility in our patients to the general infertility patient population, to describe the coexistent medical pathologies within our population at initial presentation to infertility care, and to discuss how our clinic is addressing the gap in infertility care. PRECIS: Resident-run clinics offer a unique role in increasing access to care through preconception care and low-cost fertility treatment.

Implementing Community Clinical Linkages in Underserved Communities: Lessons Learned from Six Community-Based Organizations.

This report highlights the efforts of six community-based organizations (CBOs) implementing community-clinical linkages (CCLs) to identify individuals with hypertension in underserved populations and connect them to community health centers (CHCs) participating in the National Hypertension Control Initiative. This report emphasizes the importance of understanding the CBOs' capacity to implement CCLs.

Development of a Technology-Based Dyadic Intervention for Underserved Colorectal Cancer Patients and Caregivers.

This study develops a technology-based dyadic intervention to enhance symptom management and health equity in underserved patients with colorectal cancer and their caregivers. Leveraging generative artificial intelligence, the intervention provides tailored educational contents to meet individual unmet needs.

Academic Medical Centers and Federally Qualified Health Centers: Collaboration for the Care of Underserved Communities.

Academic Medical Centers (AMCs) and Federally Qualified Health Centers (FQHCs) are similarly tasked with managing the health of their local community, yet they each face unique challenges in their ability to do so. Integrating AMCs and FQHCs into novel care delivery models can leverage both organizations strengths, providing care in a comprehensive and sustainable fashion. Johns Hopkins Medicine (JHM) implemented this model with a large East Baltimore medical center, creating an AMC-FQHC collaboration focused on providing care to the East Baltimore patient population. This system provided various improvements in care delivery, including increased staffing, new wraparound services, improved access to funding dollars, and decreased out of pocket costs for patients qualifying for financial assistance. The academic missions of research and training were preserved, serving as the primary continuity clinic for several residency programs and as a community site for research. These changes resulted in more robust care for patients while improving the financial standing of the clinic. Through AMC and FQHC partnership, progress can be made toward providing holistic and financially sustainable primary care services in underserved areas while preserving the tripartite mission of academic medicine, with significant pedagogical and research opportunities.

Providing care in underresourced areas: contribution of the physician assistant/associate workforce.

BACKGROUND: Prior studies suggest that physician assistants/associates (PAs) are more likely than physicians to work in underresourced areas. However, data characterizing the current PA workforce in health professional shortage areas (HPSAs) and medically underserved areas (MUAs) are lacking. METHODS: We analyzed the 2022 cross-sectional dataset from a comprehensive national database to examine the demographic and practice characteristics of PAs working in HPSAs/MUAs compared to those in other settings. Analyses included descriptive and bivariate statistics, along with multivariate logistic regression. RESULTS: Nearly 23% of PAs reported practicing in HPSAs/MUAs. Among PAs in HPSAs/MUAs, over a third (34.6%) work in primary care settings, 33.3% identify as men, 15.6% reside in rural/isolated areas, and 14.0% are from an underrepresented in medicine (URiM) background. Factors associated with higher odds of practicing in a HPSA/MUA included residing in rural/isolated settings, URiM background, and speaking a language other than English with patients. CONCLUSIONS: As the PA profession grows, knowledge of these attributes may help inform efforts to expand PA workforce contributions to address provider shortages.

Supporting Underserved Communities for Health Care: US Immigrants' Experiences with Social Support.

Background: Social support is associated with improved clinical outcomes but is understudied among US immigrants. We examined two types of social support, perceived health provider support and community support, and characterized perceptions of social support among US immigrants compared with nonimmigrants. Methods: We conducted cross-sectional data analysis on self-reported data from Health Information National Trends Survey 5, Cycle 2. Population-level estimates were obtained using jack-knife replicate weights. Results: Immigrant status was not associated with perceived health care provider support or community support. However, compared with nonimmigrants, US immigrants were more likely to report rarely (adjusted odds ratio [aOR]=3.07) or never (aOR=3.18) having access to emotional support. Conclusions: Further research that incorporates nuanced factors (eg, time since arrival) that may influence social support in diverse US immigrant groups is needed to determine the impact of social support on health outcomes in an underserved and often overlooked population.

Describing a medical school's rural activity footprint: setting selection and workforce distribution priorities.

CONTEXT: There is growing evidence supporting a shift towards 'grow your own' approaches to recruiting, training and retaining health professionals from and for rural communities. To achieve this, there is a need for sound methodologies by which universities can describe their area of geographic focus in a precise way that can be utilised to recruit students from their region and evaluate workforce outcomes for partner communities. In Australia, Deakin University operates a Rural Health Multidisciplinary Training (RHMT) program funded Rural Clinical School and University Department of Rural Health, with the purpose of producing a graduate health workforce through the provision of rural clinical placements in western and south-western Victoria. The desire to establish a dedicated Rural Training Stream within Deakin's Doctor of Medicine course acted as a catalyst for us to describe our 'rural footprint' in a way that could be used to prioritise local student recruitment as well as evaluate graduate workforce outcomes specifically for this region. ISSUE: In Australia, selection of rural students has relied on the Australian Statistical Geography Standard Remoteness Areas (ASGS-RA) or Modified Monash Model (MMM) to assign rural background status to medical course applicants, based on a standard definition provided by the RHMT program. Applicants meeting rural background criteria may be preferentially admitted to any medical school according to admission quotas or dedicated rural streams across the country. Until recently, evaluations of graduate workforce outcomes have also used these rurality classifications, but often without reference to particular geographic areas. Growing international evidence supports the importance of place-based connection and training, with medical graduates more likely to work in a region that they are from or in which they have trained. For universities to align rural student recruitment more strategically with training in specific geographic areas, there is a need to develop precise geographical definitions of areas of rural focus that can be applied during admissions processes. LESSONS LEARNED: As we strived to describe our rural activity area precisely, we modelled the application of several geographical and other frameworks, including the MMM, ASGS-RA, Primary Healthcare Networks (PHN), Local Government Areas (LGAs), postcodes and Statistical Areas. It became evident that there was no single geographical or rural framework that (1) accurately described our area of activity, (2) accurately described our desired workforce focus, (3) was practical to apply during the admissions process. We ultimately settled on a bespoke approach using a combination of the PHN and MMM to achieve the specificity required. This report provides an example of how a rural activity footprint can be accurately described and successfully employed to prioritise students from a geographical area for course admission. Lessons learned about the strengths and limitations of available geographical measures are shared. Applications of a precise footprint definition are described including student recruitment, evaluation of workforce outcomes for a geographic region, benefits to stakeholder relationships and an opportunity for more nuanced RHMT reporting.

International Medical Graduates and the Physician Workforce.

Importance: Physician shortages and the geographic maldistribution of general and specialist physicians impair health care delivery and worsen health inequity in the US. International medical graduates (IMGs) represent a potential solution given their ready supply. Observations: Despite extensive clinical experience, evidence of competence, and willingness to practice in underserved communities, IMGs experience multiple barriers to entry in the US, including the immigration process, the pathways available for certification and licensing, and institutional reluctance to consider non-US-trained candidates. International medical graduates applying to postgraduate training programs compare favorably with US-trained candidates in terms of clinical experience, prior formal postgraduate training, and research, but have higher application withdrawal rates and significantly lower residency and fellowship match rates, a disparity that may be exacerbated by the recent elimination of objective performance metrics, such as the US Medical Licensing Examination Step 1 score. Once legally in the US, IMGs encounter additional obstacles to board eligibility, research funding, and career progression. Conclusions and Relevance: International medical graduates offer a viable and available solution to bridge the domestic physician supply gap, while improving workforce diversity and meaningfully addressing the public health implications of geographic maldistribution of general and specialist physicians, without disrupting existing physician stature and salaries. The US remains unable to integrate IMGs until systematic policy changes at the national level are implemented.

Pathways to Medicine.

Early exposure to health careers has the potential to improve diversity in the health professional workforce and reduce health provider shortages in Rhode Island and across the United States. Rhode Island alone has 13 federally designated Primary Care Health Professional Shortage Areas (PCHPSA) and 12 Medically Underserved Areas (MUA). To help increase healthcare access for individuals residing in these areas and promote diversity within the RI health workforce, The Warren Alpert Medical School of Brown University established and/or supports multiple pathway programs to provide early health career exposure to students. This approach empowers and supports students from various backgrounds to see themselves as future healthcare professionals. These programs work to create a more well-rounded healthcare workforce equipped to serve the state's diverse patient population.

The role, the risk, and the reciprocity: creating positive early rural placements in medical education.

INTRODUCTION: The Northern Ontario School of Medicine University seeks to address rural physician shortages in Northern Ontario. One key strategy the school employs is the use of experiential learning placements embedded throughout its undergraduate curriculum. In second year, students embark on two 4-week placements in rural and remote communities. This study sought to explore the factors that contribute to a positive learning experience from the preceptor's perspective. METHODS: Semi-structured interviews were conducted with five community preceptors who have participated in these placements. Using the information from these interviews a survey was created and sent to another 15 preceptors. Data were analyzed using qualitative methods and frequencies. RESULTS: Three key themes were identified from both the interviews and survey data: the role of early rural and remote placements; the risks of these placements; and the need for a reciprocal relationship between institutions, preceptors, and students to create a positive learning environment. CONCLUSION: Preceptors value the opportunity to teach students, but the aims of these placements are not clear and preceptors and local hospitals need more workforce resources to make these experiences positive.

L'activité odontologique hospitalière dans l'offre de soins en zone sous-dotée : exemple en Basse-Normandie.

INTRODUCTION: Demand for dental care in Basse-Normandie has been severely affected by the reduced availability of local services. One of the missions of hospital dental services is to respond to these difficulties in accessing care. PURPOSE OF THE RESEARCH: The objective of this study is to determine how hospital activity fits into the local dental care offer. To do this, we compared the activity of the dental service of the Caen hospital with that of private practices. RESULTS: The proportion of young patients, particularly those under fifteen, was greater at the university hospital than in private practice (20.9 percent vs 12.9 percent, p < 1.10 -5). The activity of private practices included a higher proportion of fixed prosthetic care and oral prophylaxis procedures, in contrast to surgical procedures, direct restorative care, and consultations, which account for a higher proportion of hospital activity (10 percent vs 22.5 percent, p < 1.10-5). CONCLUSIONS: The dental service at Caen hospital differs from private practices in Basse-Normandie in that its activity is oriented toward primary care or emergency care. This activity seems to reflect a high individual caries risk, probably associated with social vulnerability. The unit therefore seems to respond to a need for primary care.