Evaluation of the Effectiveness of a Bilingual Nutrition Education Program in Partnership with a Mobile Health Unit.

There are limited reports of community-based nutrition education with culinary instruction that measure biomarkers, particularly in low-income and underrepresented minority populations. Teaching kitchens have been proposed as a strategy to address social determinants of health, combining nutrition education, culinary demonstration, and skill building. The purpose of this paper is to report on the development, implementation, and evaluation of Journey to Health, a program designed for community implementation using the RE-AIM planning and evaluation framework. Reach and effectiveness were the primary outcomes. Regarding reach, 507 individuals registered for the program, 310 participants attended at least one nutrition class, 110 participants completed at least two biometric screens, and 96 participants attended at least two health coaching appointments. Participants who engaged in Journey to Health realized significant improvements in body mass index, blood pressure, and triglycerides. For higher risk participants, we additionally saw significant improvements in total and LDL cholesterol. Regarding dietary intake, we observed a significant increase in cups of fruit and a decrease in sugar sweetened beverages consumed per day. Our findings suggest that Journey to Health may improve selected biometrics and health behaviors in low-income and underrepresented minority participants.

Can stepped collaborative care interventions improve post-traumatic stress disorder symptoms for racial and ethnic minority injury survivors?

Objectives: No large-scale randomized clinical trial investigations have evaluated the potential differential effectiveness of early interventions for post-traumatic stress disorder (PTSD) among injured patients from racial and ethnic minority backgrounds. The current investigation assessed whether a stepped collaborative care intervention trial conducted at 25 level I trauma centers differentially improved PTSD symptoms for racial and ethnic minority injury survivors. Methods: The investigation was a secondary analysis of a stepped wedge cluster randomized clinical trial. Patients endorsing high levels of distress on the PTSD Checklist (PCL-C) were randomized to enhanced usual care control or intervention conditions. Three hundred and fifty patients of the 635 randomized (55%) were from non-white and/or Hispanic backgrounds. The intervention included care management, cognitive behavioral therapy elements and, psychopharmacology addressing PTSD symptoms. The primary study outcome was PTSD symptoms assessed with the PCL-C at 3, 6, and 12 months postinjury. Mixed model regression analyses compared treatment effects for intervention and control group patients from non-white/Hispanic versus white/non-Hispanic backgrounds. Results: The investigation attained between 75% and 80% 3-month to 12-month follow-up. The intervention, on average, required 122 min (SD=132 min). Mixed model regression analyses revealed significant changes in PCL-C scores for non-white/Hispanic intervention patients at 6 months (adjusted difference -3.72 (95% CI -7.33 to -0.10) Effect Size =0.25, p<0.05) after the injury event. No significant differences were observed for white/non-Hispanic patients at the 6-month time point (adjusted difference -1.29 (95% CI -4.89 to 2.31) ES=0.10, p=ns). Conclusion: In this secondary analysis, a brief stepped collaborative care intervention was associated with greater 6-month reductions in PTSD symptoms for non-white/Hispanic patients when compared with white/non-Hispanic patients. If replicated, these findings could serve to inform future American College of Surgeon Committee on Trauma requirements for screening, intervention, and referral for PTSD and comorbidities. Level of evidence: Level II, secondary analysis of randomized clinical trial data reporting a significant difference. Trial registration number: NCT02655354.

Racial and ethnic minorities in lower income brackets are associated with late-stage diagnosis of non-ocular melanoma.

INTRODUCTION: Despite advances in oncologic care, racial and socio-economic outcome disparities persist in non-ocular melanoma patients. However, the unmet need is understanding the population at risk for late tumor stage at diagnosis. We sought to analyze the groups with an increased risk of unfavorable tumor stage at diagnosis. METHODS: Patients with non-ocular melanoma were reviewed using the 2000-2019 SEER Research Data (SEER*Stat) and grouped into early tumor stage at diagnosis (stage I-IIC) and late (stage III-IVC). Multivariable logistic and Cox regression examined the association of demographic, socioeconomic, and clinical factors with late-stage diagnosis and overall survival, respectively. Kaplan-Meier estimates were calculated with racial and county-level household income stratification to evaluate overall survival differences. RESULTS: Of 147,606 patients diagnosed with non-ocular melanoma, 38,695 cases were identified based on inclusion and exclusion criteria and separated into those with early-stage diagnosis (median 63 years) and those with late-stage (median 62 years). Male gender, Black race, Asian or Pacific Islander race, and Hispanic ethnicity were significantly associated with late-stage tumor diagnosis (p < 0.001). Receipt of surgery and a median county-level household income >$75,000 were protective for late-stage tumor diagnosis (p < 0.001). Additionally, male gender, Black, Asian or Pacific Islander, American Indian/Alaskan Native races, metastasis, and late-stage diagnosis were associated with factors significantly associated with decreased overall survival (p-value <0.001). Receipt of surgery and a median household income of $50,000-$74,999 and >$75,000 were factors associated with increased overall survival (p < 0.001). The median overall survival was 89 months, but Black patients (58 months) and <$50,000 income households (75 months) had significantly worse survival (p < 0.001). CONCLUSIONS: Hispanic ethnicity, Black and Asian or Pacific Islander race, and low-income households were associated with late-stage non-ocular melanoma at diagnosis. Black, Asian or Pacific Islander and American Indian/Alaskan Native races and lower-income households were associated with worse overall survival. Identifying addressable causal factors that link this at-risk population to poor cancer prognosis is warranted.

Master of Public Health in Health Equity and Criminal Justice: Student and Alumni Feedback on the Development of a New Master of Public Health Concentration.

Purpose: To describe Master of Public Health (MPH) student and alumni interest in a new Health Equity and Criminal Justice (HECJ) concentration, highlight their personal experiences with mass incarceration, and summarize their input on developing the concentration. Methods: From July to October 2017 current MPH students and alumni at Touro University California (Vallejo, CA) were electronically surveyed. Results: The 152 respondents included those who had focused exclusively on public health, and those who concurrently obtained clinical degrees in osteopathic medicine, pharmacy, or physician assistant studies. Approximately 90% of the current and former students surveyed believed HECJ to be an integral part of public health, and one in three respondents described being personally impacted by incarceration. More than half (64%) were interested in the HECJ concentration, and 81% of those respondents were interested in completing their field study internship at a correctional facility. Conclusion: The HECJ concentration will fill an educational gap and may provide a pedagogical model for training a future generation of public health professionals to mitigate the health impacts of the U.S. mass incarceration epidemic.

Improving Health Equity and Reducing Pediatric Cancer Disparities: The Role of the Medical Home.

The advances in pediatric cancer outcomes over the last quarter century are some of the most successful in modern medicine. Improved diagnostics and novel therapies have led to continued increases in the survival rates of most patients; however, not all populations have benefitted equally. Compared to White children, Black, Indigenous, People of Color patients with cancer more often present with advanced stage illness, less frequently participate in clinical trials, and are more likely to be lost to follow-up once therapy is complete. Proposed hypotheses for these disparities include both biologic and nonbiologic factors, and a growing body of research suggests that barriers influencing care from diagnosis through survivorship are important. In this article, we consider how primary pediatricians can help reduce disparities over the cancer continuum by identifying vulnerable populations, considering potential diagnoses, referring to cancer centers, and following up with patients through survivorship in partnership with the oncology team. [Pediatr Ann. 2022;51(1):e22-e26.].

Structural Racism and Breast Cancer-specific Survival: Impact of Economic and Racial Residential Segregation.

OBJECTIVE: To analyze the effect of economic and racial/ethnic residential segregation on breast cancer-specific survival (BCSS) in South Florida, a diverse metropolitan area that mirrors the projected demographics of many United States regions. SUMMARY BACKGROUND DATA: Despite advances in diagnosis and treatment, racial and economic disparities in BCSS. This study evaluates these disparities through the lens of racial and economic residential segregation, which approximate the impact of structural racism. METHODS: Retrospective cohort study of stage I to IV breast cancer patients treated at our institution from 2005 to 2017. Our exposures include index of concentration at the extremes, a measurement of economic and racial neighborhood segregation, which was computed at the census-tract level using American Community Survey data. The primary outcome was BCSS. RESULTS: Random effects frailty models predicted that patients living in low-income neighborhoods had higher mortality compared to those living in high-income neighborhoods [hazard ratios (HR): 1.56, 95% confidence interval (CI): 1.23-2.00]. Patients living in low-income non-Hispanic Black and Hispanic neighborhoods had higher mortality compared to those living in high-income non-Hispanic White (NHW) neighborhoods (HR: 2.43, 95%CI: 1.72, 3.43) and (HR: 1.99, 95%CI: 1.39, 2.84), after controlling for patient characteristics, respectively. In adjusted race-stratified analysis, NHWs living in low-income non-Hispanic Black neighborhoods had higher mortality compared to NHWs living in high-income NHW neighborhoods (HR: 4.09, 95%CI: 2.34-7.06). CONCLUSIONS: Extreme racial/ethnic and economic segregation were associated with lower BCSS. We add novel insight regarding NHW and Hispanics to a growing body of literature that demonstrate how the ecological effects of structural racism-expressed through poverty and residential segregation-shape cancer survival.

Survival outcomes in an older US population with advanced melanoma and central nervous system metastases: SEER-Medicare analysis.

BACKGROUND: Central nervous system (CNS) metastasis is common in advanced melanoma patients. New treatment options have improved overall prognosis, but information is lacking for patients with CNS metastases. We investigated treatment patterns and survival outcomes in older melanoma patients with and without CNS metastases. METHODS: A retrospective analysis of SEER-Medicare, a population-based linked database, was undertaken in patients aged > 65 years with advanced melanoma diagnosed from 2004 to 2011 and followed until 2013. RESULTS: A total of 2522 patients were included. CNS metastases were present in 24.8% of patients at initial metastatic diagnosis; 16.5% developed CNS metastases during follow-up. Chemotherapy was the most common treatment regardless of CNS metastases. Overall survival (OS) was better for patients without CNS metastases (median, 9.5 months; 95% confidence interval [CI], 8.8-10.2) vs patients with CNS metastases (3.63 months; 95% CI, 3.4-3.9). Among patients with CNS metastases, median OS for targeted therapy, immunotherapy, and chemotherapy was 6 (95% CI, 2.5-9.6), 5.5 (95% CI, 3.8-7.5), and 4.5 (95% CI, 3.8-5.4) months, respectively, vs 2.4 (95% CI, 2.1-2.7) and 2.1 (95% CI, 1.8-2.7) months for local radiotherapy and no treatment, respectively. Stereotactic radiosurgery demonstrated higher OS vs whole-brain radiation therapy (median, 4.98 [95% CI, 3.5-7.5] vs 2.4 [95% CI, 2.1-2.7] months). CONCLUSION: Patients with CNS metastases from melanoma remain a population with high unmet medical need despite recent advances in treatment. Systemic treatments (eg, BRAF-targeted therapy and immunotherapy) and stereotactic radiosurgery demonstrated meaningful but modest improvements in OS. Further explorations of combinations of radiotherapy, BRAF-targeted therapies, and immunotherapies are needed.

Developing a Health Equity and Criminal Justice Concentration for a Master of Public Health (MPH) Program: Results From a Needs Assessment Among Community Partners and Potential Employers.

The United States has experienced a 4-fold increase in jail and prison populations over the last 40 years, disproportionately burdening African American and Hispanic/Latinx communities. Mass incarceration threatens the health of individuals, families, and communities, and requires a public health response. The Master of Public Health (MPH) Program at Touro University California (TUC) trains students to become skillful, socially-conscious public health professionals. We are developing a concentration focused on the public health impacts of incarceration. Along with the core public health curriculum, students of this new "Health Equity and Criminal Justice (HECJ)" concentration will receive training in criminal justice, reentry, reintegration, recidivism, restorative justice, structural racism, and social and community impacts of incarceration. Our study gauges interest in an HECJ concentration in our local community, including potential employers. We surveyed a cross-section of community partners including public health departments, other governmental agencies, California correctional facilities, county jails, community groups, health clinics, and hospitals. A majority (89%) of respondents consider mass incarceration a public health problem and 86% believe specialized training would make graduates employable by criminal justice related organizations. The HECJ track will fill a gap in the field and train a future generation of public health professionals to address the epidemic of mass incarceration.

Telemedicine as a tool to mitigate cardiometabolic risk associated with serious mental illness.

People with serious mental illness suffer from substantially higher rates of cardiometabolic morbidity and mortality than the general population. We have evaluated the efficacy of telemedicine for providing cardiometabolic risk management services compared to in-person care. A retrospective chart review was conducted in order to compare changes in body mass index (BMI), systolic blood pressure and serum triglycerides before and after telemedicine (n=38). The comparator group (n=38) was selected from a list of all clients who had a conventional appointment at the metabolic clinic. Analysis of Variance showed an overall effect of treatment on BMI (P<0.001), but no significant differences between the groups on BMI (P=0.89), systolic blood pressure (P=0.62) or fasting serum triglycerides (P=0.81). This suggests that telemedicine may be as effective as in-person care and that telemedicine has the potential to improve access to cardiometabolic risk management services for people with serious mental illness.

A long way from home: comparing mental health measures between foreign and U.S.-born Latinos in the Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND: Studies exploring the relationship between foreign-born status and mental health among Latinos in the United States have varied in their conclusions. We examined 2000-2002 MESA data on Latinos and compared responses between immigrants and non-immigrants on the Center for Epidemiologic Studies Depression (CES-D) scale and the Spielberger anxiety and anger scales. METHODS: We used logistic and linear regression to examine whether immigrant status was associated with these psychological outcomes in Latinos-overall, Mexicans-only and Other-Latinos (non-Mexicans). RESULTS: Compared with U.S.-born Latinos, foreign-born Latinos had significantly higher odds of meeting CES-D caseness- a score above 16, classifying depressive symptoms (p≤.05), higher anger scores (p≤.001) and a trend towards higher anxiety. These associations were similar within the Mexicans-only subgroup. DISCUSSION: When examining self-reported distress symptoms as outcomes, our findings do not coincide with the paradoxical effect of immigration on mental health. Furthermore, associations between immigrant status and psychological outcomes differed among the Latino subgroups.

Sponsorship of physical activity programs by the sweetened beverages industry: public health or public relations?

The growing evidence on the association between consumption of sugar-sweetened beverages, obesity and other chronic diseases has highlighted the need to implement policy actions that go beyond programs exclusively focused on individual responsibility. In order to protect their commercial goals in Latin America, the sugar-sweetened beverage industry practices intense lobbying at high government levels in several countries across the region. This strategy is accompanied by corporate social responsibility programs that fund initiatives promoting physical activity. These efforts, although appearing altruistic, are intended to improve the industry's public image and increase political influence in order to block regulations counter to their interests. If this industry wants to contribute to human well being, as it has publicly stated, it should avoid blocking legislative actions intended to regulate the marketing, advertising and sale of their products.

Assessment of ultrasound for use in detecting lipoatrophy in HIV-infected patients taking combination antiretroviral therapy.

The aim of this study was evaluation of ultrasound (US) as a tool for the assessment of lipoatrophy in a population of HIV-infected patients. We enrolled a convenience sample of 151 HIV-infected Caucasian participants (males, 79%) who were treated for at least 1 year with combination antiretroviral therapy (CART) in Zagreb, Croatia. US measurements of subcutaneous fat thickness were done over the malar, brachial, and crural region. We determined sensitivity and specificity of US as a diagnostic tool for lipoatrophy using receiver-operating curves and concordant patient and clinician assessment as our reference for the presence of lipoatrophy. HIV was acquired through heterosexual contact in 50% of participants and by sex between men in 42%. The mean current CD4 cell count was 503.1 cells=mm3 (standard deviation [SD] = 250.8). Seventy-seven (51%) participants were treated with stavudine and 91 (64%) with a protease inhibitor for at least 6 months. Nineteen (13%)participants had lipoatrophy in at least one anatomic site. Sensitivity of US ranged from 67%-71%, specificity from 65%-71%, positive and negative predictive values ranged from 11%-20% and 96-97%, respectively. US diagnosed lipoatrophy was more frequently found in patients with a history of stavudine treatment and in females. Patients with lipoatrophy had a longer duration of CART than those without lipoatrophy. US is a useful tool in ruling out the presence of clinical lipoatrophy in patients on CART. Using this objective measure of subcutaneous fat may be useful in helping clinicians make decisions about changing therapy.