Community-Based COVID-19 Vaccine Clinics in Medically Underserved Neighborhoods to Improve Access and Equity, Philadelphia, 2021-2022.

Vaccination remains key to reducing the risk of COVID-19-related severe illness and death. Because of historic medical exclusion and barriers to access, Black communities have had lower rates of COVID-19 vaccination than White communities. We describe the efforts of an academic medical institution to implement community-based COVID-19 vaccine clinics in medically underserved neighborhoods in Philadelphia, Pennsylvania. Over a 13-month period (April 2021-April 2022), the initiative delivered 9038 vaccine doses to community members, a majority of whom (57%) identified as Black. (Am J Public Health. 2022;112(12):1721-1725. https://doi.org/10.2105/AJPH.2022.307030).

Who, What, and Where: Transforming Primary Care Education to Advance Health Equity.

To transform primary care with the goal of achieving health equity, changes in the way the health care workforce is selected, trained, and ultimately delivers care should be expedited. Research has repeatedly shown the immense impact of the social determinants of health and the gaps related to health equity in the United States. Despite this knowledge, health care education and delivery systems have been slow to evolve. The Health Resources and Services Administration established the Academic Units for Primary Care Training and Enhancement to work towards strengthening the primary care workforce. Through their research, the six individual Academic Units (AU) have identified gaps related to health equity in their areas of focus. This article provides recommendations from the AUs on ways primary care health professions education can be transformed to advance health equity and serves as background for the articles to follow in the remainder of the supplement.

Ongoing challenges in access to diabetes care among the indigenous population: perspectives of individuals living in rural Guatemala.

BACKGROUND: Indigenous persons living in Latin America suffer from a higher prevalence of type 2 diabetes compared to their non-indigenous counterparts. This difference has been attributed to a wide range of factors. Future interventions could be influenced by a deeper understanding of the challenges that impact care in rural regions and in other low-income settings. METHODS: This study was conducted using a modified grounded theory approach. Extended observations and fifteen interviews were performed with adult male and female residents of three rural Mayan towns in Sololá Department, Guatemala using purposive sampling. Questions focused on the perceptions of individuals living with type 2 diabetes and their caregivers regarding disease and treatment. RESULTS: Across interviews the most common themes that emerged included mistreatment by healthcare providers, mental health comorbidity, and medication affordability. These perceptions were in part influenced by indigeneity, poverty, and/or gender. CONCLUSIONS: Both structural and cultural barriers continue to impact diabetes care for indigenous communities in rural Guatemala. The interviews in this study suggest that indigenous people experience mistrust in the health care system, unreliable access to care, and mental health comorbidity in the context of type 2 diabetes care. These experiences are shaped by the complex relationship among poverty, gender, and indigeneity in this region. Targeted interventions that are conscious of these factors may increase their chances of success when attempting to address similar health disparities in comparable populations.

Medical Student Exposure to Integrated Behavioral Health.

OBJECTIVE: Integrated behavioral health (IBH) allows for effective care delivery for patients with mental health and behavioral health disorders in primary care settings. This study assesses the state of exposure current medical students have to the IBH model in family medicine clerkships, in order to augment the readiness of students to participate in IBH as developing professionals. METHODS: Clerkship directors at US and Canadian medical schools with a required family medicine run course (n = 141) were asked to estimate the percentage of students exposed to IBH in their clerkships, as part of the Council of Academic Family Medicine Educational Research Alliance (CERA) 2016 survey. RESULTS: The response rate was 86% (n = 118). Forty-four percent of clerkship directors reported that 0-20% of students are exposed to the IBH model in their clerkships. A comparison of schools with low and high exposure showed no significant differences among clerkship characteristics. CONCLUSIONS: A majority of medical students in the USA and Canada are not exposed to IBH models during their primary care clerkship. Larger systematic studies are needed to elucidate the steps necessary to prepare graduating medical students to collaborate in IBH models.

Diabetes prevalence in rural Indigenous Guatemala: A geographic-randomized cross-sectional analysis of risk.

BACKGROUND: Developing countries and Indigenous populations are disproportionately affected by global trends in diabetes (T2DM), but inconsistent data are available to corroborate this pattern in Guatemala and indigenous communities in Central America. Historic estimates of T2DM, using a variety of sampling techniques and diagnostic methods, in Guatemala include a T2DM prevalence of: 4·2% (1970) and 8·4% (2003). Objectives of this geographically randomized, cross-sectional analysis of risk include: (1) use HbA1c to determine prevalence of T2DM and prediabetes in rural Indigenous community of Atitlán (2) identify risk factors for T2DM including age, BMI and gender. METHODS: A spatially random sampling method was used to identify 400 subjects. Prevalence was compared using the confidence interval method, and logistic regression and linear regression were used to assess association between diabetes and risk factors. FINDINGS: The overall prevalence of T2DM using HbA1c was 13·81% and prediabetes was also 13·81% in Atitlán, representing a tripling in diabetes from historic estimates and a large population with pre-diabetes. The probability of diabetes increased dramatically with increasing age, however no significant overall relationship existed with gender or BMI. CONCLUSIONS: Diabetes is a larger epidemic than previously expected and appears to be related to ageing rather than BMI. Our proposed explanations for these findings include: possible Indigenous unique genetic susceptibility to T2DM, shortcomings in BMI as a metric for adiposity in assessing risk, changes in lifestyle and diet, and an overall aging population. The conclusion of this study suggest that (1) T2DM in rural regions of Guatemala may be of epidemic proportion. With pre-diabetes, more than 25% of the population will be diabetic in the very near future; (2) Age is a significant risk factor in the Indigenous population but BMI is not. This suggests that in some populations diabetes may be a disease of ageing.

Identifying Prevalence and Characteristics of Behavioral Health Education in Family Medicine Clerkships: A CERA Study.

BACKGROUND AND OBJECTIVES: Many patients with behavioral health disorders do not seek or receive adequate care for their conditions. Among those that do, most will receive care in a primary care setting. To best meet this need, clinicians will need to demonstrate proficiency of behavioral health skills and evidence-based practices. We sought to explore the degree to which these skills are being taught in family medicine clerkships. METHODS: The Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) 2016 survey of clerkship directors (CDs) was sent to 141 CDs at US and Canadian medical schools with a required family medicine run course. CDs were asked about the inclusion of behavioral health topics, tools, and techniques in the clerkship, as well as rating the importance of these items. RESULTS: Eighty-six percent of CDs completed the survey. Mood disorders (81.4%) were most frequently taught, followed by anxiety disorders (77.8%), substance use disorders (74.4%), and impulse control disorders (39.1%). Screening tools and behavioral health counseling skills were less commonly taught. CONCLUSIONS: Many behavioral health topics are not taught universally to all family medicine clerkship students. Gaps exist between what is included in current curriculum and what is recommended by the National Clerkship Curriculum for family medicine. These gaps may represent challenges for improving the care for patients with behavioral health disorders.

The Guatemala-Penn Partners: An Innovative Inter-Institutional Model for Scientific Capacity-Building, Healthcare Education, and Public Health.

Population health outcomes are directly related to robust public health programs, access to basic health services, and a well-trained health-care workforce. Effective health services need to systematically identify solutions, scientifically test these solutions, and share generated knowledge. The World Health Organization (WHO)'s Global Healthcare Workforce Alliance states that the capacity to perform research is an essential factor for well-functioning public health systems. Low- and middle-income countries have greater health-care worker shortages and lower research capacity than higher-income countries. International global health partnerships between higher-income countries and low-middle-income countries aim to directly address such inequalities through capacity building, a process by which human and institutional resources are strengthened and developed, allowing them to perform high-level functions, solve complex problems, and achieve important objectives. The Guatemala-Penn Partners (GPP) is a collaboration among academic centers in Guatemala and the University of Pennsylvania (Penn), in Philadelphia, Pennsylvania that echoes the vision of the WHO's Global Healthcare Workforce Alliance. This article describes the historical development and present organization of the GPP according to its three guiding principles: university-to-university connections, dual autonomies with locally led capacity building, and mutually beneficial exchanges. It describes the GPP activities within the domains of science, health-care education, and public health, emphasizing implementation factors, such as sustainability and scalability, in relation to the guiding principles. Successes and limitations of this innovative model are also analyzed in the hope that the lessons learned may be applied to similar partnerships across the globe.

The relationship between pay day and violent death in Guatemala: a time series analysis.

OBJECTIVE: To assess if violent deaths were associated with pay days in Guatemala. DESIGN: Interrupted time series analysis. SETTING: Guatemalan national autopsy databases. PARTICIPANTS: Daily violence-related autopsy data for 22 418 decedents from 2009 to 2012. Data were provided by the Guatemalan National Institute of Forensic Sciences. Multiple pay-day lags and other important days such as holidays were tested. OUTCOME MEASURES: Absolute and relative estimates of excess violent deaths on pay days and holidays. RESULTS: The occurrence of violent deaths was not associated with pay days. However, a significant association was observed for national holidays, and this association was more pronounced when national holidays and pay days occurred simultaneously. This effect was observed mainly in males, who constituted the vast majority of violent deaths in Guatemala. An estimated 112 (coefficient=3.12; 95% CI 2.15 to 4.08; p<0.01) more male violent deaths occurred on holidays than were expected. An estimated 121 (coefficient=4.64; 95% CI 3.41 to 5.88; p<0.01) more male violent deaths than expected occurred on holidays that coincided with the first 2 days following a pay day. CONCLUSIONS: Men in Guatemala experience violent deaths at an elevated rate when pay days coincide with national holidays. Efforts to be better prepared for violence during national holidays and to prevent violent deaths by rescheduling pay days when these days co-occur with national holidays should be considered.

Impact of store-and-forward (SAF) teledermatology on outpatient dermatologic care: A prospective study in an underserved urban primary care setting.

BACKGROUND: The clinical value of teledermatology in the primary care setting remains relatively unknown. OBJECTIVE: We sought to determine the impact of teledermatology on outpatient diagnosis, management, and access to dermatologic care in a resource-poor primary care setting. METHODS: We performed a prospective study of store-and-forward teledermatology consults submitted between January and November 2013 from 11 underserved clinics in Philadelphia to the University of Pennsylvania using mobile devices and the Internet. We assessed diagnostic and management concordance between primary care providers and dermatologists, time to consult completion, anticipated level of dermatology input in the absence of teledermatology, and number of consults managed with teledermatology alone. RESULTS: The study included 196 consults encompassing 206 dermatologic conditions. Diagnoses and management plans of primary care providers and dermatologists were fully concordant for 22% and 23% of conditions, respectively. The median time to consult completion was 14 (interquartile range 3-28) hours. At least 61% of consults would not otherwise have received dermatology input, and 77% of consults were managed with teledermatology alone. LIMITATIONS: Lack of a diagnostic gold standard, limited patient follow-up, and uncertain generalizability are limitations. CONCLUSION: Teledermatology is an innovative and impactful modality for delivering dermatologic care to outpatients in resource-poor primary care settings.

Primary care providers' perceptions of mobile store-and-forward teledermatology.

INTRODUCTION: Although teledermatology offers promise as a tool to increase access to care, adoption has been limited. Understanding the perspectives and experiences of key stakeholders, such as primary care providers (PCPs) and patients, is important to identify opportunities to reduce barriers to adoption and to improve teledermatology programs. Although many studies have examined patients' experiences and satisfaction with teledermatology, few have examined referring PCPs' perspectives. OBJECTIVE: To identify PCPs' perceptions on the strengths and limitations of teledermatology in order to identify opportunities to improve teledermatology programs. METHODS: We distributed an anonymous, web-based survey to 30 PCPs involved in a two-year study evaluating a mobile app-based teledermatology platform. RESULTS: 100% (18/18) agreed or strongly agreed that teledermatology increases access to dermatologic care, improves patient care, and is acceptable to patients. 100% (18/18) agreed or strongly agreed that teledermatology provides educational benefit to the PCP. Only 6% (1/18) agreed that teledermatology increases medical liability and 11% (2/18) agreed that it increases risk of a breach in privacy or confidentiality. CONCLUSIONS: Our findings highlight that PCPs are highly satisfied with mobile app-based, store-and-forward teledermatology and that they believe teledermatology offers synergistic educational benefit. We hope these results will help guide the development of teledermatology programs to increase access to timely, cost-effective care.

A random spatial sampling method in a rural developing nation.

BACKGROUND: Nonrandom sampling of populations in developing nations has limitations and can inaccurately estimate health phenomena, especially among hard-to-reach populations such as rural residents. However, random sampling of rural populations in developing nations can be challenged by incomplete enumeration of the base population. METHODS: We describe a stratified random sampling method using geographical information system (GIS) software and global positioning system (GPS) technology for application in a health survey in a rural region of Guatemala, as well as a qualitative study of the enumeration process. RESULTS: This method offers an alternative sampling technique that could reduce opportunities for bias in household selection compared to cluster methods. However, its use is subject to issues surrounding survey preparation, technological limitations and in-the-field household selection. Application of this method in remote areas will raise challenges surrounding the boundary delineation process, use and translation of satellite imagery between GIS and GPS, and household selection at each survey point in varying field conditions. This method favors household selection in denser urban areas and in new residential developments. CONCLUSIONS: Random spatial sampling methodology can be used to survey a random sample of population in a remote region of a developing nation. Although this method should be further validated and compared with more established methods to determine its utility in social survey applications, it shows promise for use in developing nations with resource-challenged environments where detailed geographic and human census data are less available.

Comparison of textbook to fmCases on family medicine clerkship exam performance.

BACKGROUND AND OBJECTIVES: The use of online learning with virtual cases has become commonplace in medical education. A series of fmCASES has been developed to assist with learning for clerkship students in family medicine. It has not been shown whether this series of cases improves student learning during their clerkship compared to traditional learning modalities. METHODS: We designed an intervention study to replace the traditional family medicine clerkship textbook with the fmCASES curriculum at one medical school. We then compared two consecutive cohorts of family medicine clerkship students by examining their performance on overall and small groups of exam questions at the end of the clerkship. RESULTS: Data were obtained for 95% of students across the 2-year study. Overall performance on the end of clerkship exam was unchanged with the transition to fmCASES. Student performance was variable based on subject area and source of examination question. CONCLUSIONS: Using a set of online cases to replace a traditional textbook did not change overall performance on the end-of-clerkship assessment. However, our findings suggest that students demonstrated proficiency in answering questions that came from the sources they studied from. This finding should be considered when curricula transition to greater use of online learning resources.

An exploration of violence, mental health and substance abuse in post-conflict Guatemala.

Guatemala's 36-year civil war officially ended in December 1996 after some 200,000 deaths and one million refugees. Despite the ceasefire, Guatemala continues to be a violent country with one of the highest homicide rates in the world. We investigated potential associations between violence, mental health, and substance abuse in post-conflict Guatemala using a community-based survey of 86 respondents living in urban and rural Guatemala. Overall, 17.4% of our respondents had at least one, direct violent experience during the civil war. In the post-conflict period, 90.7% of respondents reported being afraid that they might be hurt by violence, 40.7% screened positive for depression, 50.0% screened positive for PTSD, and 23.3% screened positive for alcohol dependence. Potential associations between prior violent experiences during the war and indicators of PTSD and aspects of alcohol dependence were found in regression-adjusted models (p < 0.05). Certain associations between prior civil war experiences, aspects of PTSD and alcohol dependence in this cohort are remarkable, raising concerns for the health and safety of the largely indigenous populations we studied. Higher than expected rates of depression, PTSD, and substance abuse in our cohort may be related to the ongoing violence, injury and fear that have persisted since the end of the civil war. These, in turn, have implications for the growing medical and surgical resources needed to address the continuing traumatic and post-traumatic complications in the post-conflict era. Limitations of the current study are discussed. These findings are useful in beginning to understand the downstream effects of the Guatemalan civil war, although a much larger, randomly sampled survey is now needed.

Willingness to pay for emergency referral transport in a developing setting: a geographically randomized study.

OBJECTIVES: The objective was to identify the correlates of willingness to pay for ambulance transports from a rural city to a regional hospital in Guatemala. METHODS: An innovative methodology that utilizes a novel randomization technique and satellite imagery was used to select a sample of homes in Santiago Atitlán, Guatemala. The respondents were surveyed at these homes about their willingness to pay for ambulance transport to a regional hospital. A price ladder was used to elicit respondents' willingness to pay for ambulance transport, depending on the level of severity of three types of emergencies: life-threatening emergencies, disability-causing emergencies, and simple emergencies. Simple and multiple linear regression modeling was used to identify the social and economic correlates of respondents' willingness to pay for ambulance transport and to predict demand for ambulance transport at a variety of price levels. Beta coefficients (ß) expressed as percentages with 95% confidence intervals (CIs) were estimated. RESULTS: The authors surveyed 134 respondents (response rate=3.3%). In the multivariable regression models, three variables correlated with willingness to pay: household income, location of residence (rural district vs. urban district), and respondents' education levels. Correlates for ambulance transport in life-threatening emergencies included greater household daily income (ß=1.32%, 95% CI=0.63% to 2.56%), rural location of residence (ß=-37.3%, 95% CI=-51.1% to -137.5%), and higher educational levels (ß=4.41%, 95% CI=1.00% to 6.36%). Correlates of willingness to pay in disability-causing emergencies included greater household daily income (ß=1.59%, 95% CI=0.81% to 3.19%) and rural location of residence (ß=-19.4%, 95% CI=-35.7% to -89.4%). Correlates of willingness to pay in simple emergencies included rural location of residence (ß=59.4%, 95% CI=37.9% to 133.7%) and higher educational levels (ß=7.96%, 95% CI=1.96% to 11.8%). At all price levels, more individuals were willing to pay for transport for a life-threatening emergency than a disability-causing emergency. Respondents' willingness to pay was more responsive to price changes for transport during disability-causing emergencies than for transport during life-threatening emergencies. CONCLUSIONS: The primary correlates of willingness to pay for ambulance transport in Santiago Atitlán, Guatemala, are household income, location of residence (rural district vs. urban district), and respondents' education levels. Furthermore, severity of emergency significantly appears to influence how much individuals are willing to pay for ambulance transport. Willingness-to-pay information may help public health planners in resource-poor settings develop price scales for health services and achieve economically efficient allocations of subsidies for referral ambulance transport.

Coca-colonization and hybridization of diets among the Tz'utujil Maya.

Biomedical health professionals express increasing concern that rising consumption of soft drinks and processed foods in Mayan and Latin American eating patterns may lead to detrimental nutritional and health consequences. Scholars debate whether the pervading presence of Coca-Cola and Pepsi in developing countries represents "Coca-Colonization," synonymous with cultural imperialism, or cultural hybridization. Using mixed qualitative and quantitative research methods, including participant observation and semi-structured interviews, this study explores the development of Coca-Colonization and cultural hybridization among the Tz'utujil Maya of Santiago Atitlán, Guatemala. By specifically examining biomedical perspectives, cycles of conquest, the political economy, religion, celebrations, and the physical environment through the lens of soft drinks, this study finds that Coca-Colonization and cultural hybridization are complementary rather than mutually exclusive processes that contribute to dietary transitions, economic development, and differential health beliefs related to soft drink consumption.

Criticisms of chlorination: social determinants of drinking water beliefs and practices among the Tz'utujil Maya.

OBJECTIVE: To explore social determinants of drinking water beliefs and practices among the Tz'utujil Maya of Santiago Atitlán, Guatemala, through analysis of demographics, socioeconomic status, memory of historical events, sensory experience, and water attitudes. METHODS: Parallel mixed (qualitative and quantitative) methods, including participant observation, in-depth interviews based on a purposive sample, and 201 semi-structured interviews based on a regional quota sample, were used to collect data from March 2007 to August 2008. Data analysis included the use of grounded theory methodology and Pearson's chi-square test for independence. RESULTS: Qualitative results based on grounded theory highlighted how memory of the Guatemalan Civil War and Hurricane Stan, attitudes about Lake Atitlán water, and the taste and smell of chlorine influenced Tz'utujil Maya drinking water beliefs. Quantitative survey results revealed that differences in ethnicity, literacy, years of schooling, distrust of the water supply during the Civil War and Hurricane Stan, and current beliefs about Lake Atitlán and tap water quality were associated with significantly different water self-treatment practices. CONCLUSIONS: In accordance with social determinants of health paradigms, demographic, socioeconomic, social, cultural, political, and historical factors continue to be significant determinants of water-related health. Public health water interventions must address inequalities related to these underlying factors in order to achieve maximum effectiveness.

Criticisms of chlorination: social determinants of drinking water beliefs and practices among the Tz'utujil Maya / Críticas a la cloración: factores sociales determinantes de las creencias y prácticas con respecto al agua potable de la población Maya Tz'utujil

OBJECTIVE: To explore social determinants of drinking water beliefs and practices among the Tz'utujil Maya of Santiago Atitlán, Guatemala, through analysis of demographics, socioeconomic status, memory of historical events, sensory experience, and water attitudes. METHODS: Parallel mixed (qualitative and quantitative) methods, including participant observation, in-depth interviews based on a purposive sample, and 201 semi-structured interviews based on a regional quota sample, were used to collect data from March 2007 to August 2008. Data analysis included the use of grounded theory methodology and Pearson's chi-square test for independence. RESULTS: Qualitative results based on grounded theory highlighted how memory of the Guatemalan Civil War and Hurricane Stan, attitudes about Lake Atitlán water, and the taste and smell of chlorine influenced Tz'utujil Maya drinking water beliefs. Quantitative survey results revealed that differences in ethnicity, literacy, years of schooling, distrust of the water supply during the Civil War and Hurricane Stan, and current beliefs about Lake Atitlán and tap water quality were associated with significantly different water self-treatment practices. CONCLUSIONS: In accordance with social determinants of health paradigms, demographic, socioeconomic, social, cultural, political, and historical factors continue to be significant determinants of water-related health. Public health water interventions must address inequalities related to these underlying factors in order to achieve maximum effectiveness.

OBJETIVO: Explorar los factores sociales determinantes de las creencias y prácticas con respecto al agua potable de la población maya tz'utujil, que habita en Santiago Atitlán (Guatemala), mediante el análisis de la información demográfica, la situación socioeconómica, la memoria de hechos históricos, la experiencia sensorial y las actitudes con respecto al agua. MÉTODOS: De marzo del 2007 a agosto del 2008, se recopilaron datos por medio de métodos paralelos mixtos (tanto cualitativos como cuantitativos), como la observación de participantes, entrevistas en profundidad basadas en un muestreo intencionado y 201 entrevistas semiestructuradas basadas en un muestreo por cuota regional. En el análisis de los datos se usó el método de la teoría fundamentada o muestreo teórico y la prueba de la chi al cuadrado de Pearson para la independencia. RESULTADOS: Los resultados cualitativos basados en la teoría fundamentada pusieron de relieve que los recuerdos de la guerra civil guatemalteca y del huracán Stan, las actitudes acerca del agua del Lago Atitlán, y el gusto y el olor del cloro influían las creencias de los tz'utujiles con respecto al agua potable. Los resultados cuantitativos de la encuesta indicaron que las diferencias a raíz del grupo étnico, el alfabetismo, los años de escolaridad, la desconfianza del abastecimiento de agua durante la guerra civil y el huracán Stan, y las creencias actuales acerca de la calidad del agua del Lago Atitlán y del agua de grifo estaban asociadas con prácticas de autotratamiento del agua sumamente diferentes. CONCLUSIONES: En consonancia con el paradigma de los factores sociales determinantes de la salud, los factores demográficos, socioeconómicos, sociales, culturales, políticos e históricos siguen siendo determinantes significativos de la salud en relación con el agua. Para que puedan lograr la mayor eficacia posible, las intervenciones de salud pública con respecto al agua deben abordar las desigualdades relacionadas con estos factores fundamentales.