"We have to lie low that sort of poisons me more and more": A qualitative study of violent political rhetoric and health implications for Spanish and Chinese speaking immigrants.

BACKGROUND: In recent years, the historical legacy of anti-immigrant sentiment in the US has resurfaced, fueled by a new wave of anti-immigrant political rhetoric. Violent political rhetoric, defined as either explicit or metaphorically targeted language to dehumanize targeted groups, can incite discriminatory treatment of immigrants at both interpersonal and institutional levels, shaping their health and healthcare experiences. This qualitative study explores and compares how Spanish- and Chinese-speaking immigrant populations in Chicago make sense of violent political rhetoric against their racial and ethnic identities, utilize coping strategies to maintain their sense of belonging, and experience downstream health consequences. METHODS: In 2019, 14 semi-structured focus groups were conducted among immigrants to the U.S. (n = 79). Participants were recruited from four community sites in either Hispanic/Latino or Chinese neighborhoods in Chicago. Focus groups were conducted by racially- and linguistically concordant interviewers in Spanish, Mandarin, or Cantonese. The research team developed a codebook iteratively and analyzed transcripts using grounded theory and the constant comparison method. RESULTS: Participants included Chinese (61%) and Spanish-speaking immigrants (39%), with an average age of 61.4 years (sd = 13); the majority were female (62%), unemployed (68%), and attained less than a high school diploma (53%). Self-reported stress due to political rhetoric was more pronounced among Spanish-speaking participants (93%) than Chinese participants (39.6%). Immigrants responded to manifestations of violent political rhetoric in numerous ways including mobilizing the model minority myth with internalized racism, anticipatory stress, and "high effort" coping mechanisms (John Henryism), all with downstream health effects. CONCLUSION: Violent political rhetoric is one of the mechanisms by which racism and xenophobia exacerbate a toll on the health of racialized immigrant groups. These processes have implications for both interpersonal and institutional experiences, as well as health and healthcare interactions. We propose a conceptual model that outlines these mechanisms and points to potential areas of intervention to ameliorate immigrant health inequities.

"We're playing on the same team": Communication (dis)connections between trauma patients and surgical residents.

BACKGROUND: Patient-physician communication is key to better clinical outcomes and patient well-being. Communication between trauma patients and their physicians remains relatively unexplored. We aimed to identify and characterize the range of strengths and challenges in patient-physician communication in the setting of trauma care. METHODS: A qualitative, grounded theory approach was used to explore communication strengths and challenges for patients and residents. Patients previously admitted to the trauma service for violent injuries were recruited and interviewed in-person during their trauma clinic appointments. Surgical residents were recruited via email and interviewed virtually via Zoom. Anonymous, semistructured interviews were conducted until thematic saturation was reached. RESULTS: Twenty-nine interviews with patients and 14 interviews with residents were conducted. Patients reported feeling ignored and misunderstood and having inadequate communication with physicians. Residents cited lack of time, patients' lack of health literacy, differences in background, and emotional responses to trauma as barriers to effective communication with patients. Patients and residents reported an understanding of each other's stressors, similar emotional experiences regarding traumatic stress, and a desire to communicate with each other in greater depth both inside and outside of the hospital. CONCLUSION: Trauma patients and residents can feel disconnected due to the lack of time for thorough communication and differences in background; however, they understand each other's stressors and share similar emotional responses regarding trauma and a desire for increased communication, connection, and solidarity. Leveraging these shared values to guide interventions, such as a resident curriculum, may help bridge disconnects and improve their communication. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

A Systematic Review and Meta-Analysis of Food Insecurity and Dyslipidemia.

PURPOSE: There is considerable interest in the association between food insecurity (FIS) and various cardiovascular risk factors such as dyslipidemia. Although the association between FIS and dyslipidemia has been studied across various methodologies and populations, there is no comprehensive systematic review and meta-analysis of these data. METHODS: A systematic literature search was conducted. Cross-sectional peer-review studies assessing the association between FIS and dyslipidemia were identified. Data extracted included population characteristics, study sizes, covariates explored, and laboratory assessments of dyslipidemia. Effect sizes were extracted or calculated, then synthesized across studies using a random effect model, and the heterogeneity, publication bias, and subgroup dependence for each meta-analysis were assessed. RESULTS: For adults, meta-analysis demonstrated no significantly elevated odds for FIS individuals to have a concomitant abnormal lipid measurement. Covariate-unadjusted analysis of standardized mean differences showed no significant differences in lipid measurements between food-insecure and food-secure individuals. In contrast to quantitative laboratory results, food-insecure patients were more likely to self-report previous diagnoses of dyslipidemia. CONCLUSIONS: Although current data do not suggest an association between FIS and dyslipidemia, more longitudinal studies and studies targeting women, children, the elderly, and patients with chronic diseases such as diabetes are needed to further address this issue.

Medical Spanish Endocrinology Educational Module.

Introduction: Hispanic/Latinx patients experience health disparities in endocrine disease, such as higher rates of mortality due to diabetes mellitus, worse outcomes in the surgical treatment of thyroid cancer, and lack of knowledge about bone health and osteoporotic fracture prevention. Educational strategies to teach cultural and linguistic medical Spanish knowledge to medical students have the potential to improve Hispanic/Latinx endocrine health. Methods: We created an 8-hour medical Spanish endocrine module targeting language and cultural skills acquisition. Specifically, students practiced obtaining a past medical history, obtaining a medications history, providing and explaining a diagnosis, explaining discharge instructions, and discussing sociocultural aspects of endocrine health. We divided the module into four 2-hour sessions: (1) preclass self-study, (2) class period, (3) role-play/interviewing practice session, and (4) case/cultural activity assignment. Participants completed a pre- and postassessment to measure student confidence level and knowledge. Results: We implemented the module four times at one medical school, with 47 fourth-year medical students with intermediate or higher general Spanish skills. Confidence increased for all learners in the endocrine-focused interview and exam in Spanish. Heritage Spanish learners, who were exposed to Spanish at home as children, reported higher postmodule confidence in eliciting the past medical history of endocrine problems. Discussion: The medical Spanish endocrine module improved the communication skills of medical students with intermediate through advanced Spanish proficiency. Future study should evaluate learner clinical performance metrics and applications to other groups of learners, such as resident physicians or health professions involved in the care of patients with endocrine disease.

Food insecurity, type 2 diabetes, and hyperglycaemia: A systematic review and meta-analysis.

AIMS: Food insecurity (FIS) is a major public health issue with possible implications for type 2 diabetes mellitus (T2DM) risk. We conducted a systematic review and meta-analysis to explore the association between FIS and T2DM. METHODS: We performed a systematic search in PubMed, Embase, Scopus, and Web of Science. All cross-sectional, peer-reviewed studies investigating the link between FIS and T2DM were included. Population characteristics, study sizes, covariates, T2DM diagnoses, and diabetes-related clinical measures such as fasting blood glucose (FBG) and HbA1c were extracted from each study. Outcomes were compared between food insecure and food secure individuals. Effect sizes were combined across studies using the random effect model. RESULTS: Forty-nine peer-reviewed studies investigating the link between FIS and T2DM were identified (n = 258,250). Results of meta-analyses showed no association between FIS and clinically determined T2DM either through FBG or HbA1c: OR = 1.22 [95%CI: 0.96, 1.55], Q(df = 5) = 12.5, I2  = 60% and OR = 1.21 [95%CI: 0.95, 1.54], Q(df = 5) = 14; I2  = 71% respectively. Standardized mean difference (SMD) meta-analyses yielded no association between FIS and FBG or HbA1c: g = 0.06 [95%CI: -0.06, 0.17], Q(df = 5) = 15.8, I2  = 68%; g = 0.11 [95% CI: -0.02, 0.25], Q(df = 7) = 26.8, I2  = 74% respectively. For children, no association was found between FIS and HbA1c: g = 0.06 [95%CI: 0.00, 0.17], Q(df = 2) = 5.7, I2  = 65%. CONCLUSIONS: Despite multiple proposed mechanisms linking FIS to T2DM, integration of the available literature suggests FIS is not associated with clinically determined T2DM or increases in FBG or HbA1c among adult patients.

Associations of Race, Insurance, and Zip Code-Level Income with Nonadherence Diagnoses in Primary and Specialty Diabetes Care.

INTRODUCTION: Evidence suggests that clinicians may view or label patients as nonadherent in a biased manner. Therefore, we performed a retrospective cohort analysis exploring associations between patient demographics and zip code-level income with the International Classification of Diseases, Tenth Version (ICD-10) diagnoses for nonadherence among type 2 diabetes mellitus (T2DM) patients, comparing primary and specialty care settings. Providers in the primary care group included internal medicine and family medicine physicians. In the specialty care group, providers included endocrinologists and diabetologists only. METHODS: Participants were identified from 5 primary care and 4 endocrinology sites in the University of Pennsylvania Health System between January 1, 2015, and January 1, 2019. Demographics, hemoglobin A1c (HbA1c), and ICD-10 codes for T2DM and nonadherence were extracted from the electronic health record and analyzed in October 2019. Log-binomial regression models were used to estimate patients' risk of nonadherence labeling by race, insurance, and zip code-level median household income, controlling for patient characteristics and HbA1c as a proxy for diabetes self-management. Results were compared between primary and specialty care sites. RESULTS: A total of 6072 patients aged 18-70 years were included in this study. Black race, Medicare, and Medicaid were associated with increased nonadherence labeling while controlling for patient characteristics ([ARR = 2.48, 95% CI: 2.01, 3.04], [ARR = 1.82, 95% CI: 1.50, 2.18], [ARR = 1.61, 95% CI: 1.32, 1.93], respectively). The results remained significant on adjustment with zip code-level income and showed no differences between primary and specialty sites. Lower-income zip codes showed a significant association with increased rates of nonadherence labeling. CONCLUSIONS: Black race, non-private insurance, and lower-income zip codes were associated with disproportionately high rates of nonadherence labeling in both primary and specialty management of T2DM, possibly suggestive of racial or class bias.

Medical Spanish Musculoskeletal and Dermatologic Educational Module.

Introduction: While many medical schools provide opportunities in medical Spanish for medical students, schools often struggle with identifying a structured curriculum. The purpose of this module was to provide a flexible, organ system-based approach to teaching and learning musculoskeletal and dermatologic Spanish terminology, patient-centered communication skills, and sociocultural health contexts. Methods: An 8-hour educational module for medical students was created to teach musculoskeletal and dermatologic medical communication skills in Spanish within the Hispanic/Latinx cultural context. Participants included 47 fourth-year medical students at an urban medical school with a starting minimum Spanish proficiency at the intermediate level. Faculty provided individualized feedback on speaking, listening, and writing performance of medical Spanish skills, and learners completed a written pre- and postassessment testing skills pertaining to communication domains of vocabulary, grammar, and comprehension as well as self-reported confidence levels. Results: Students demonstrated improvement in vocabulary, grammar, comprehension, and self-confidence of musculoskeletal and dermatologic medical Spanish topics. While students with overall lower starting proficiency levels (intermediate) scored lower on the premodule assessment compared to higher proficiency students (advanced/native), the postmodule assessment did not show significant differences in skills performance among these groups. Discussion: An intermediate Spanish level prerequisite for this musculoskeletal and dermatologic module can result in skills improvement for all learners despite starting proficiency variability. Future study should evaluate learner clinical performance and integration of this module into other educational settings such as graduate medical education (e.g., orthopedic, rehabilitation, and dermatology residency programs) and other health professions (e.g., physical therapy and nursing).

Food insecurity and hypertension: A systematic review and meta-analysis.

BACKGROUND: Food insecurity (FIS) is an important public health issue associated with cardiovascular risk. Given the association of FIS with diets of poorer nutritional quality and higher salt intake as well as chronic stress, numerous studies have explored the link between FIS and hypertension. However, no systematic review or meta-analysis has yet to integrate or analyze the existing literature. METHODS: We performed a wide and inclusive search of peer-reviewed quantitative data exploring FIS and hypertension. A broad-terms, systematic search of the literature was conducted in PubMed, Embase, Scopus, and Web of Science for all English-language, human studies containing primary data on the relationship between FIS and hypertension. Patient population characteristics, study size, and method to explore hypertension were extracted from each study. Effect sizes including odds ratios and standardized mean differences were extracted or calculated based on studies' primary data. Comparable studies were combined by the random effects model for meta-analyses along with assessment of heterogeneity and publication bias. RESULTS: A total of 36 studies were included in the final analyses. The studies were combined into different subgroups for meta-analyses as there were important differences in patient population characteristics, methodology to assess hypertension, and choice of effect size reporting (or calculability from primary data). For adults, there were no significantly increased odds of elevated blood pressures for food insecure individuals in studies where researchers measured the blood pressures: OR = 0.91 [95%CI: 0.79, 1.04; n = 29,781; Q(df = 6) = 7.6; I2 = 21%]. This remained true upon analysis of studies which adjusted for subject BMI. Similarly, in studies for which the standardized mean difference was calculable, there was no significant difference in measured blood pressures between food secure and FIS individuals: g = 0.00 [95%CI: -0.04, 0.05; n = 12,122; Q(df = 4) = 3.6; I2 = 0%]. As for retrospective studies that inspected medical records for diagnosis of hypertension, there were no significantly increased odds of hypertension in food insecure adults: OR = 1.11 [95%CI: 0.86, 1.42; n = 2,887; Q(df = 2) = 0.7; I2 = 0%]. In contrast, there was a significant association between food insecurity and self-reports of previous diagnoses of hypertension: 1.46 [95%CI: 1.13, 1.88; n = 127,467; Q(df = 7) = 235; I2 = 97%]. Only five pediatric studies were identified which together showed a significant association between FIS and hypertension: OR = 1.44 [95%CI: 1.16, 1.79; n = 19,038; Q(df = 4) = 5.7; I2 = 30%]. However, the small number of pediatric studies were not sufficient for subgroup meta-analyses based on individual study methodologies. DISCUSSION: In this systematic review and meta-analysis, an association was found between adult FIS and self-reported hypertension, but not with hypertension determined by blood pressure measurement or chart review. Further, while there is evidence of an association between FIS and hypertension among pediatric subjects, the limited number of studies precluded a deeper analysis of this association. These data highlight the need for more rigorous and longitudinal investigations of the relationship between FIS and hypertension in adult and pediatric populations.