A catchment and location-allocation analysis of mammography access in Delaware, US: implications for disparities in geographic access to breast cancer screening.

BACKGROUND: Despite a 40% reduction in breast cancer mortality over the last 30 years, not all groups have benefited equally from these gains. A consistent link between later stage of diagnosis and disparities in breast cancer mortality has been observed by race, socioeconomic status, and rurality. Therefore, ensuring equitable geographic access to screening mammography represents an important priority for reducing breast cancer disparities. Access to breast cancer screening was evaluated in Delaware, a state that experiences an elevated burden from breast cancer but is otherwise representative of the US in terms of race and urban-rural characteristics. We first conducted a catchment analysis of mammography facilities. Finding evidence of disparities by race and rurality, we next conducted a location-allocation analysis to identify candidate locations for the establishment of new mammography facilities to optimize equitable access. METHODS: A catchment analysis using the ArcGIS Pro Service Area analytic tool characterized the geographic distribution of mammography sites and Breast Imaging Centers of Excellence (BICOEs). Poisson regression analyses identified census tract-level correlates of access. Next, the ArcGIS Pro Location-Allocation analytic tool identified candidate locations for the placement of additional mammography sites in Delaware according to several sets of breast cancer screening guidelines. RESULTS: The catchment analysis showed that for each standard deviation increase in the number of Black women in a census tract, there were 68% (95% CI 38-85%) fewer mammography units and 89% (95% CI 60-98%) fewer BICOEs. The more rural counties in the state accounted for 41% of the population but only 22% of the BICOEs. The results of the location-allocation analysis depended on which set of screening guidelines were adopted, which included increasing mammography sites in communities with a greater proportion of younger Black women and in rural areas. CONCLUSIONS: The results of this study illustrate how catchment and location-allocation analytic tools can be leveraged to guide the equitable selection of new mammography facility locations as part of a larger strategy to close breast cancer disparities.

A Suicide Prevention Intervention for Emerging Adult Sexual and Gender Minority Groups: Protocol for a Pilot Hybrid Effectiveness Randomized Controlled Trial.

BACKGROUND: Suicide attempts and suicide death disproportionately affect sexual and gender minority emerging adults (age 18-24 years). However, suicide prevention strategies tailored for emerging adult sexual and gender minority (EA-SGM) groups are not widely available. The Safety Planning Intervention (SPI) has strong evidence for reducing the risk for suicide in the general population, but it is unclear how best to support EA-SGM groups in their use of a safety plan. Our intervention (Supporting Transitions to Adulthood and Reducing Suicide [STARS]) builds on content from an existing life skills mobile app for adolescent men who have sex with men (iREACH) and seeks to target core risk factors for suicide among EA-SGM groups, namely, positive affect, discrimination, and social disconnection. The mobile app is delivered to participants randomized to STARS alongside 6 peer mentoring sessions to support the use of the safety plan and other life skills from the app to ultimately reduce suicide risk. OBJECTIVE: We will pilot-test the combination of peer mentoring alongside an app-based intervention (STARS) designed to reduce suicidal ideation and behaviors. STARS will include suicide prevention content and will target positive affect, discrimination, and social support. After an in-person SPI with a clinician, STARS users can access content and activities to increase their intention to use SPI and overcome obstacles to its use. EA-SGM groups will be randomized to receive either SPI alone or STARS and will be assessed for 6 months. METHODS: Guided by the RE-AIM (reach, efficacy, adoption, implementation, and maintenance) framework, we will recruit and enroll a racially and ethnically diverse sample of 60 EA-SGM individuals reporting past-month suicidal ideation. Using a type-1 effectiveness-implementation hybrid design, participants will be randomized to receive SPI (control arm) or to receive SPI alongside STARS (intervention arm). We will follow the participants for 6 months, with evaluations at 2, 4, and 6 months. Preliminary effectiveness outcomes (suicidal ideation and behavior) and hypothesized mechanisms of change (positive affect, coping with discrimination, and social support) will serve as our primary outcomes. Secondary outcomes include key implementation indicators, including participants' willingness and adoption of SPI and STARS and staff's experiences with delivering the program. RESULTS: Study activities began in September 2021 and are ongoing. The study was approved by the institutional review board of the University of Pennsylvania (protocol number 849500). Study recruitment began on October 14, 2022. CONCLUSIONS: This project will be among the first tailored, mobile-based interventions for EA-SGM groups at risk for suicide. This project is responsive to the documented gaps for this population: approaches that address chosen family, focus on a life-course perspective, web approaches, and focus on health equity and provision of additional services relevant to sexual and gender minority youth. TRIAL REGISTRATION: ClinicalTrials.gov NCT05018143; https://classic.clinicaltrials.gov/ct2/show/NCT05018143. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/48177.

Alignment of Ending the HIV Epidemic Priority Jurisdictions With Availability of HIV Service Organizations: An Ecological Study.

We sought to describe and quantify the association between HIV service organization availability, HIV burden, and HIV awareness and prevention in the 57 priority jurisdictions selected as part of the U.S. Ending the HIV Epidemic initiative. On average, jurisdictions with more per capita organizations had more people living with HIV, more individuals aware of their positive status, and more individuals prescribed PrEP (b = 0.3; 95% CI [0.2, 0.5] for each additional case per 1,000 people in the first metric, and b = 0.3; 95% CI [0.2, 0.4] and b = 0.1; 95% CI [< 0.1, 0.1], respectively, for each percentage point change in the second two metrics), accounting for jurisdiction size. Several jurisdictions were outliers in the modeled associations and may reflect comparatively better, or worse, performance than similar jurisdictions. This information can assist in evaluating resource allocation and determining whether availability translates to accessibility.

A Catchment and Location-Allocation Analysis of Mammography Access in Delaware, US: Implications for disparities in geographic access to breast cancer screening.

Background: Despite a 40% reduction in breast cancer mortality over the last 30 years, not all groups have benefited equally from these gains. A consistent link between later stage of diagnosis and disparities in breast cancer mortality has been observed by race, socioeconomic status, and rurality. Therefore, ensuring equitable geographic access to screening mammography represents an important priority for reducing breast cancer disparities. This study conducted a catchment and location-allocation analysis of mammography access in Delaware, a state that is representative of the US in terms of race and urban-rural characteristics and experiences an elevated burden from breast cancer. Methods: A catchment analysis using the ArcGIS Pro Service Area analytic tool characterized the geographic distribution of mammography sites and Breast Imaging Centers of Excellence (BICOEs). Poisson regression analyses identified census tract-level correlates of access. Next, the ArcGIS Pro Location-Allocation analytic tool identified candidate locations for the placement of additional mammography sites in Delaware according to several sets of breast cancer screening guidelines. Results: The catchment analysis showed that for each standard deviation increase in the number of Black women in a census tract, there were 64% (95% CI, 0.18-0.66) fewer mammography units and 85% (95% CI, 0.04-0.48) fewer BICOEs. The more rural counties in the state accounted for 41 % of the population but only 22% of the BICOEs. The results of the location-allocation analysis depended on which set of screening guidelines were adopted, which included increasing mammography sites in communities with a greater proportion of younger Black women and in rural areas. Conclusions: The results of this study illustrate how catchment and location-allocation analytic tools can be leveraged to guide the equitable selection of new mammography facility locations as part of a larger strategy to close breast cancer disparities.

Accessibility of HIV Services in Philadelphia: Location-Allocation Analysis.

INTRODUCTION: As the first step in the HIV care continuum, timely diagnosis is central to reducing transmission of the virus and ending the HIV epidemic. Studies have shown that distance from a testing site is essential for ease of access to services and educational material. This study shows how location-allocation analysis can be used to improve allocation of HIV testing services utilizing existing publicly available data from 2015 to 2019 on HIV prevalence, testing site location, and factors related to HIV in Philadelphia, Pennsylvania. METHODS: The ArcGIS Location-Allocation analytic tool was used to calculate locations for HIV testing sites using a method that minimizes the distance between demand-point locations and service facilities. ZIP code level demand was initially specified on the basis of the percentage of late HIV diagnoses and in a sensitivity analysis on the basis of a composite of multiple factors. Travel time and distance from demand to facilities determined the facility location allocation. This analysis was conducted from 2021 to 2022. RESULTS: Compared with the 37 facilities located in 20 (43%) Philadelphia ZIP codes, the model proposed reallocating testing facilities to 37 (79%) ZIP codes using percent late diagnoses to define demand. On average, this would reduce distance to the facilities by 65% and travel time to the facilities by 56%. Results using the sensitivity analysis were similar. CONCLUSIONS: A wider distribution of HIV testing services across the city of Philadelphia may reduce distance and travel time to facilities, improve accessibility of testing, and in turn increase the percentage of people with knowledge of their status.

Disparities of COVID-19 and HIV Occurrence Based on Neighborhood Infection Incidence in Philadelphia, Pennsylvania.

Objectives. To evaluate the occurrence of HIV and COVID-19 infections in Philadelphia, Pennsylvania, through July 2020 and identify ecological correlates driving racial disparities in infection incidence. Methods. For each zip code tabulation area, we created citywide comparison Z-score measures of COVID-19 cases, new cases of HIV, and the difference between the scores. Choropleth maps were used to identify areas that were similar or dissimilar in terms of disease patterning, and weighted linear regression models helped identify independent ecological predictors of these patterns. Results. Relative to COVID-19, HIV represented a greater burden in Center City Philadelphia, whereas COVID-19 was more apparent in Northeast Philadelphia. Areas with a greater proportion of Black or African American residents were overrepresented in terms of both diseases. Conclusions. Although race is a shared nominal upstream factor that conveys increased risk for both infections, an understanding of separate structural, demographic, and economic risk factors that drive the overrepresentation of COVID-19 cases in racial/ethnic communities across Philadelphia is critical. Public Health Implications. Difference-based measures are useful in identifying areas that are underrepresented or overrepresented with respect to disease occurrence and may be able to elucidate effective or ineffective mitigation strategies. (Am J Public Health. 2022;112(3):408-416. https://doi.org/10.2105/AJPH.2021.306538).

State-Level Social and Economic Policies and Their Association With Perinatal and Infant Outcomes.

Policy Points State-level social and economic policies that expand tax credits, increase paid parental leave, raise the minimum wage, and increase tobacco taxes have been demonstrated to reduce adverse perinatal and infant health outcomes. These findings can help prioritize evidence-based legislated policies to improve perinatal and infant outcomes in the United States. CONTEXT: Rates of preterm birth and infant mortality are alarmingly high in the United States. Legislated efforts may directly or indirectly reduce adverse perinatal and infant outcomes through the enactment of certain economic and social policies. METHODS: We conducted a narrative review to summarize the associations between perinatal and infant outcomes and four state-level US policies. We then used a latent profile analysis to create a social and economic policy profile for each state based on the observed policy indicators. FINDINGS: Of 27 articles identified, nine focused on tax credits, eight on paid parental leave, four on minimum wages, and six on tobacco taxes. In all but three studies, these policies were associated with improved perinatal or infant outcomes. Thirty-three states had tax credit laws, most commonly the earned income tax credit (n = 28, 56%). Eighteen states had parental leave laws. Two states had minimum wage laws lower than the federal minimum; 14 were equal to the federal minimum; 29 were above the federal minimum; and 5 did not have a state law. The average state tobacco tax was $1.76 (standard deviation = $1.08). The latent profile analysis revealed three policy profiles, with the most expansive policies in Western and Northeastern US states, and the least expansive policies in the US South. CONCLUSIONS: State-level social and economic policies have the potential to reduce adverse perinatal and infant health outcomes in the United States. Those states with the least expansive policies should therefore consider enacting these evidence-based policies, as they have shown a demonstratable benefit in other states.

The feasibility and acceptability of mobile health monitoring for real-time assessment of traumatic injury outcomes.

BACKGROUND: Traumatic injuries are a health event that can begin a trajectory towards chronic health and social challenges. Mobile technology-based prevention and treatment interventions have been used to monitor and transform outcomes across a myriad of health conditions, but their potential in long-term injury recovery is unexplored. The goal of this pilot study was to assess the acceptability and feasibility of mobile health monitoring for long-term outcomes in a population of trauma patients with known barriers to health and social care after injury. METHODS: We re-recruited 25 individuals, 12-36 months after acute hospitalization, from a recently concluded study of psychological outcomes in seriously injured Black men in Philadelphia, Pennsylvania. This mixed- methods pilot study was conducted in three phases: (I) qualitative interviews and development of a pilot monitoring platform; (II) a 3-month feasibility trial of mobile monitoring of patient-reported outcomes and biometric data using a wrist-worn commercial fitness monitor (n=18); (III) post-implementation qualitative interviews. RESULTS: Analysis of data from pre-implementation interviews indicated that the majority of participants used smartphones as a primary means of communicating with their social network and to access the internet. The 90-day pilot trial of mobile monitoring indicated participants' preference text-delivered communication and survey elicitation. Response rates for 12 automated surveys ranged from 84-92%. Twenty-four hours a day adherence to optional biometric monitoring was generally lower than 50% but ranged widely indicating both very low adherence and very high adherence. Four of 25 participants, 2 who had opted for Fitbit monitoring, were lost to follow-up at the end of the 90-day pilot trial. In post-implementation assessments, participants endorsed the acceptability of mobile monitoring highlighting the benefit of its convenience and flexibility over in-person outcome monitoring. Participants also perceived its potential benefit in long-term engagement with health and social services to assist with the challenges they faced when attempting to achieve physical, psychological, social, and financial recovery after hospitalization. These findings were reinforced through qualitative interviews which highlighted, in addition to acceptability, the perceived value of self-monitoring through the use of wearable devices to track health data like physical activity and sleep. CONCLUSIONS: This study indicates the feasibility and acceptability of mobile health monitoring used to examine long-term injury sequalae. Future research may leverage this novel strategy, refining its application to address current limitations in the reliability and accuracy of commercially available wearable technology, relative costs and benefits of different mobile data collection strategies, integration within current clinical paradigms and generalizability across injured populations and socio-ecological environments.

Prevalence of Malaria Parasite Infections among U.S.-Bound Congolese Refugees with and without Splenomegaly.

All U.S.-bound refugees from sub-Saharan Africa receive presumptive antimalarial treatment before departing for the United States. Among U.S.-bound Congolese refugees, breakthrough malaria cases and persistent splenomegaly have been reported. In response, an enhanced malaria diagnostic program was instituted. Here, we report the prevalence of plasmodial infection among 803 U.S.-bound Congolese refugees who received enhanced diagnostics. Infections by either rapid diagnostic test (RDT) or PCR were detected in 187 (23%) refugees, with 78 (10%) by RDT only, 35 (4%) by PCR only, and 74 (9%) by both. Infections identified by PCR included 103 monoinfections (87 Plasmodium falciparum, eight Plasmodium ovale, seven Plasmodium vivax, and one Plasmodium malariae) and six mixed infections. Splenomegaly was associated with malaria detectable by RDT (odds ratio: 1.8, 95% CI: 1.0-3.0), but not by PCR. Splenomegaly was not strongly associated with parasitemia, indicating that active malaria parasitemia is not necessary for splenomegaly.

Research ethics and refugee health: a review of reported considerations and applications in published refugee health literature, 2015-2018.

INTRODUCTION: Public health investigations, including research, in refugee populations are necessary to inform evidence-based interventions and care. The unique challenges refugees face (displacement, limited political protections, economic hardship) can make them especially vulnerable to harm, burden, or undue influence. Acute survival needs, fear of stigma or persecution, and history of trauma may present challenges to ensuring meaningful informed consent and establishing trust. We examined the recently published literature to understand the application of ethics principles in investigations involving refugees. METHODS: We conducted a preliminary review of refugee health literature (research and non-research data collections) published from 2015 through 2018 available in PubMed. Article inclusion criteria were: participants were refugees, topic was health-related, and methods used primary data collection. Information regarding type of investigation, methods, and reported ethics considerations was abstracted. RESULTS: We examined 288 articles. Results indicated 33% of investigations were conducted before resettlement, during the displacement period (68% of these were in refugee camps). Common topics included mental health (48%) and healthcare access (8%). The majority (87%) of investigations obtained consent. Incentives were provided less frequently (23%). Most authors discussed the ways in which community stakeholders were engaged (91%), yet few noted whether refugee representatives had an opportunity to review investigational protocols (8%). Cultural considerations were generally limited to gender and religious norms, and 13% mentioned providing some form of post-investigation support. CONCLUSIONS: Our analysis is a preliminary assessment of the application of ethics principles reported within the recently published refugee health literature. From this analysis, we have proposed a list of best practices, which include stakeholder engagement, respect for cultural norms, and post-study support. Investigations conducted among refugees require additional diligence to ensure respect for and welfare of the participants. Development of a refugee-specific ethics framework with ethics and refugee health experts that addresses the need for stakeholder involvement, appropriate incentive use, protocol review, and considerations of cultural practices may help guide future investigations in this population.

Pathways to Help-Seeking Among Black Male Trauma Survivors: A Fuzzy Set Qualitative Comparative Analysis.

Many Black men suffer symptoms of traumatic stress in the aftermath of traumatic injury, and they also often carry social concerns, including experiences of discrimination and stigma, and a lack of financial resources. The objective of the present study was to understand how traumatic symptoms and social factors combine in complex ways toward the outcome of psychological help-seeking. We analyzed qualitative and quantitative data from 32 injured Black men admitted to a Level 1 trauma center. Qualitative interviews explored their attitudes toward seeking professional psychological help. We analyzed quantitative data, collected using validated instruments, on posttraumatic stress and depression symptoms, financial worry, and discrimination/stigma. Fuzzy set qualitative comparative analysis (fsQCA) was conducted by calibrating each condition to fuzzy set membership scores based on our knowledge of the causal conditions and the cases. We then constructed truth tables for QCA analysis using fsQCA software. Three causal pathways for psychological help-seeking were identified: Two pathways showed that severe trauma symptoms in the absence of financial worry were sufficient for seeking help, whereas the third showed that financial worry and discrimination in the absence of trauma symptoms were sufficient for help-seeking. We identified two causal pathways for negated help-seeking, in which low posttraumatic symptom severity and low levels of discrimination or financial worry were sufficient for not seeking psychological help. The QCA analysis revealed multiple pathways for psychological help-seeking among Black men who suffer trauma. These findings highlight the need for further research to understand complex pathways toward psychological help-seeking in this population.

'Sharing things with people that I don't even know': help-seeking for psychological symptoms in injured Black men in Philadelphia.

Objectives: Psychological distress is common in survivors of traumatic injury, yet across United States' trauma systems, it is rare that standard injury care integrates psychological evaluation and professional mental healthcare. The purpose of this study was to explore help-seeking for psychological symptoms in injured Black men living in Philadelphia. Design: A subset of a cohort of 551 injured Black men admitted to a Trauma Center in Philadelphia participated in qualitative interviews that explored their perceptions of psychological symptoms after injury and the factors that guided their decision to seek professional mental health help. Data from 32 participants were analyzed for narrative and thematic content. Results: Three overarching themes emerged: (1) facilitators of help-seeking, (2) barriers to help-seeking, and (3) factors underlying the decision not to consider professional help. Five participants felt that their injury-related psychological distress was severe enough to merit professional help despite any perceived barriers. Seventeen participants identified systemic and interpersonal obstacles to professional help that prevented them from seeking this kind of care. These included: financial constraints, limited access to mental healthcare services, and fear of the judgments of mental healthcare professionals. Ten participants would not consider professional help; these men perceived a lack of need and sufficiency in their existing social support networks. Conclusions: Research is needed to inform or identify interventions that diminish the impact of barriers to care, and identify from whom, where, and how professional mental health help might be more effectively offered to injured Black men in recovery environments like Philadelphia.

Emotional responses to unintentional and intentional traumatic injuries among urban black men: A qualitative study.

PURPOSE: The burden of injuries is disproportionately concentrated among Black men in the United States. Previous studies suggest that the mental health effects of trauma may vary by the intentionality of the injury (intentional vs. unintentional), yet little is known about this experience among Black men. We explored the emotional responses to traumatic injuries in the context of injury intentionality among Black men in an urban area. METHODS: We conducted semi-structured, qualitative interviews with 74 Black men who were traumatically injured. The interviews took place three months after discharge from the hospital and they were audiotaped, transcribed, and de-identified. We used systematic thematic analysis to identify themes about post-trauma emotional responses to intentional and unintentional injuries. RESULTS: The narratives of intentionally injured men revealed persistent exposure to neighborhood violence and their distrust of others including the people they knew and to whom they felt close. Survivors of unintentional injuries did not express a similar distrust of others. Our findings suggest that survivors of intentional injuries experience loss of social support following their injuries. CONCLUSIONS: Emotional responses can differ by intentionality of traumatic injury among urban Black men. Intentional injuries may be a marker for chronic exposure to violence and limited social support for recovery. Additional resources should be targeted to survivors of intentional injury who return to disadvantaged communities after medical treatment to decrease risk of re-traumatization and adverse emotional responses.

Lowering communication barriers in operating room technology.

OBJECTIVES: This paper examines the effects of new technology on team communication and information flow in a complex work environment, and offers design suggestions for improved team performance. BACKGROUND: Case study of a robot-assisted cholecystectomy procedure revealed teamwork disruption and an increase in the complexity of information flow and communication in the operating room as a result of the novel technology. A controlled experiment using a between-subjects design was conducted to test the hypothesis that providing critical information in a timely and accessible manner would increase communication efficiency and reduce errors in task performance. METHODS: Eighteen pairs of participants took part in a simulated tool-changing task in surgery under one of three communication conditions: (a) no rules, (b) scripted, or (c) automated. RESULTS: Teams in the scripted and automated conditions performed significantly faster than the no-rules teams (p < .05). Teams in the automated condition made significantly more errors than those in the scripted condition (p < .05). CONCLUSION: Scripted speech can facilitate team communication and adaptation to new technology; automatic information display interfaces are not useful if the modality is incompatible with operator expectations. APPLICATION: Information displays and communication protocols can be designed to ease adaptation to complex operating room technology.