Association of Medication Access Difficulty and COVID-19-Related Distress With Disease Flares in Rheumatology Patients During the COVID-19 Pandemic.

OBJECTIVE: Due to concerns of infection and medication disruptions during the COVID-19 pandemic, rheumatology patients at the pandemic epicenter were at risk of distress and poor health outcomes. We sought to investigate medication disruptions and COVID-19-related distress in the Bronx, New York shortly after the peak of the pandemic and determine whether factors related to the pandemic were associated with flares, disease activity, and overall health. METHODS: In the month following the epidemic peak, we surveyed adult patients and parents of pediatric patients from rheumatology clinics in the Bronx regarding medication access, medication interruptions, COVID-19 infection, COVID-19 hospitalization, and COVID-19-related distress. We examined which factors were associated with patient-reported flares, disease activity, and overall health scores in regression models accounting for sociodemographic characteristics and rheumatologic disease type. RESULTS: Of the 1,692 patients and parents of pediatric patients that were contacted, 361 (21%) responded; 16% reported medication access difficulty, 14% reported medication interruptions, and 41% reported experiencing flare(s). In a multivariable logistic regression model, medication access difficulty was associated with increased odds of flare (odds ratio [OR] 4.0 [95% confidence interval (95% CI) 1.5, 10.4]; P = 0.005), as was high COVID-19-related distress (OR 2.4 [95% CI 1.2, 4.6]; P = 0.01). In multivariable linear regression models, medication access difficulty and high COVID-19-related distress were associated with worse disease activity scores, and high COVID-19-related distress was associated with worse health scores. CONCLUSION: Medication access difficulties and flares were common among rheumatology patients from the Bronx, New York in the month following the peak of the epidemic. Medication access difficulty and COVID-19-related distress were highly associated with flare and disease activity. COVID-19-related distress was associated with overall health scores.

Pilot Project to Integrate Community and Clinical Level Systems to Address Health Disparities in the Prevention and Treatment of Obesity among Ethnic Minority Inner-City Middle School Students: Lessons Learned.

Effective obesity prevention and treatment interventions are lacking in the United States, especially for impoverished minority youths at risk for health disparities, and especially in accessible community-based settings. We describe the launch and pilot implementation evaluation of the first year of the B'N Fit POWER initiative as a middle school-based comprehensive wellness program that integrates weight management programming into existing onsite preventive and clinical services. Consistent with the existing implementation science literature, we focused on both the organizational structures that facilitate communication and the development of trust among stakeholders, students, and families and the development of realistic and timely goals to implement and integrate all aspects of the program. New implementation and programming strategies were developed and tested to increase the proportion of students screened, support the linkage of students to care, and streamline the integration of program clinical and afterschool components into routine services already offered at the school. We report on our initial implementation activities using the Standards for Reporting Implementation Studies (StaRI) framework using hybrid outcomes combining the Reach element from the RE-AIM framework with a newly conceptualized Wellness Cascade.

Engaging and sustaining adolescents in community-based participatory research: structuring a youth-friendly community-based participatory research environment.

Community-Based Participatory Research partnerships typically do not include adolescents as full community partners. However, partnering with adolescents can enhance the success and sustainability of adolescent health interventions. We partnered with adolescents to address health disparities in a low-income urban community. In partnering with youth, it is important to consider their developmental stage and needs to better engage and sustain their involvement. We also learned the value of a Youth Development framework and intentionally structuring a youth-friendly Community-Based Participatory Research environment. Finally, we will raise some ethical responsibilities to consider when working with youth partners.

Double jeopardy: what social risk adds to biomedical risk in understanding child health and health care utilization.

OBJECTIVE: The aim of this study was to test the hypothesis that children with both social and biomedical risk factors are more likely to be in poorer health and utilize more health services than those with either type of risk alone. METHODS: Variables were identified using the 1998 National Health Interview Survey and tested here on 2002 data. Dependent variables were health (poorer health rating) and service use (hospitalization or greater than 2 emergency services). High social risk was defined as greater than 2 risk factors (parental education less than high school, family income <200% of federal poverty level, and non-2-parent family). High biomedical risk was defined as having a chronic condition or birth weight <2500 grams. RESULTS: Children with either high social or biomedical risk were significantly more likely to be in poorer health (odds ratio [OR] 3.1-3.4) and to have higher utilization (OR 1.7-2.1) than children at low risk on both dimensions. Children with high risk on both dimensions were significantly more likely to be in poorer health (OR 7.8-7.9) and have higher utilization (OR 3.5-3.7) on both social and biomedical risks and those children rated high risk on either dimension alone. Overall, social risk was as powerful as biomedical risk in these models and added substantially to biomedical risk. Findings were stable using different cut points for social risk and health ratings, and different definitions of chronic condition. CONCLUSIONS: These findings have implications for health care planners and insurers in estimating the burdens on clinicians and potential costs of delivering care to those with high social risks.

Children of mothers with HIV/AIDS: unmet needs for mental health services.

OBJECTIVE: The objective of this study was to use multiple measures and sources to assess mental health over time in uninfected 8- to 12-year-old children of HIV-positive mothers. METHODS: We recruited from the New York City Division of AIDS Services and Income Support a consecutive sample of 157 single mothers who were living with an HIV-negative child aged 8 to 12. Families were randomly assigned to receive a custody planning intervention, Project Care, or standard care. Data were collected at baseline and 4 subsequent times 6 months apart. Children completed the Children's Depression Inventory; 8- to 10-year-olds completed the Terry, and 11- to 12-year-olds completed the Youth Self-Report. Mothers completed the Child Behavior Checklist. Each measure has a validated cutoff score to signify clinically significant symptoms. RESULTS: All 5 data points were available on 129 (82%) children. During 2 years, every child had a score in the clinical range (12% once, 25% twice, 26% 3 times, 27% 4 times, and 9% all 5 times). Clinically significant symptoms were most likely at baseline when mothers were sickest. Few had clinically significant symptoms based on maternal report only (5%) or child report only (8%). Chronicity of clinically significant symptoms was not related to child age or gender, maternal health or depression, parent-child relationship, or being assigned to Project Care. Although two thirds of the children received mental health services during the study, <25% did at any 1 time, and 28% of children with chronic clinically significant symptoms never received care. CONCLUSIONS: Children who are affected by AIDS should be routinely screened for psychiatric problems by using multiple measures and sources to avoid underidentification and be carefully monitored long-term.

An educational HIV pretest counseling video program for off-hours testing in the emergency department.

STUDY OBJECTIVE: Multiple barriers to traditional pretest HIV counseling make HIV testing difficult to accomplish in the emergency department setting in off hours. This study compares the educational effectiveness of a 10-minute pretest counseling video with the usual practice of a session with an HIV counselor. METHODS: This was a prospective randomized controlled trial of adult patients presenting to the urgent care area of a busy inner-city hospital. Patients either viewed an HIV educational video or spoke with an HIV counselor for pretest counseling. The video was developed by 2 of the investigators (YC, MH) and covered essential educational elements for HIV testing, as required by the New York State Department of Health. All participants completed a measure of HIV knowledge after their intervention. An equivalence analysis was performed to assess whether the video was at least as good as counseling in terms of overall mean knowledge score. RESULTS: Of 129 patients recruited for the study, 65 patients were randomized to the intervention and 64 patients to the control group. Five patients were unable to complete the study. The final analysis was based on 124 patients. Mean knowledge scores were higher in the intervention (85.3% versus 79.7%; 90% confidence interval for the difference 2.6% to 8.7%). CONCLUSION: We conclude that the use of an educational video with an inner-city adult population was at least as effective as in-person pretest counseling in conveying information related to HIV testing.

Cumulative social disadvantage and child health.

CONTEXT: Disparities in child health are a major public health concern. However, it is unclear whether these are predominantly the result of low income, race, or other social risk factors that may contribute to their health disadvantage. Although others have examined the effects of the accumulation of risk factors, this methodology has not been applied to child health. OBJECTIVE: We tested 4 social risk factors (poverty, minority race/ethnicity, low parental education, and not living with both biological parents) to assess whether they have cumulative effects on child health and examined whether access to health care reduced health disparities. DESIGN: We analyzed data on 57,553 children <18 years from the 1994 and 1995 National Health Interview Survey Disability Supplement. Of the 4 risk factors, 3 (poverty, low parental education, and single-parent household) were consistently associated with child health. These were summed, generating the Social Disadvantage Index (range: 0-3). RESULTS: A total of 43.6% of children had no social disadvantages, 30.8% had 1, 15.6% had 2, and 10.0% had all 3. Compared with those with no social disadvantages, the odds ratios (ORs) of being in "good, fair, or poor health" (versus "excellent or very good") were 1.95 for 1 risk, 3.22 for 2 risks, and 4.06 for 3 risks. ORs of having a chronic condition increased from 1.25 (1 risk) to 1.60 (2 risks) to 2.11 (3 risks). ORs for activity limitation were 1.51 (1 risk) to 2.14 (2 risks) and 2.88 (3 risks). Controlling for health insurance did not affect these findings. CONCLUSIONS: The accumulation of social disadvantage among children was strongly associated with poorer child health and having insurance did not reduce the observed health disparities.